in canada and other developed nations , licensed nursing support staff are increasingly called upon to provide technical care ( e.g. , monitoring an taking vital signs , changing simple wound dressings ) to society 's most vulnerable populations ( e.g. , the elderly , the handicapped ) . they also offer relational care to patients : empathic listening and a personalized , caring dialogue , among others services [ 2 , 3 ] . while licensed nursing - support staff have long predominated in long - term care settings , the number of licensed practical nurses ( lpns ) working in acute - care institutions is on the rise due to persistent nursing shortages and the rationalization of nursing resources . licensed practical nurse ( lpn ) ( in quebec infirmier(re ) auxiliaire ) and more rarely licensed vocational nurse ( lvn ) are the terms used in most states and provinces across north america to refer to a nursing professional who provides care for the sick , injured , convalescent , or disabled under the direction of a registered nurse . the canadian province of ontario also employs the term registered practical nurse ( rpn ) . outside of north america , the term enrolled nurse ( en ) is used in australia and new zealand and state enrolled nurse ( sen ) in the united kingdom . lpns work in a variety of settings : hospitals , residential care facilities , clinics , private homes , and doctors ' offices . a certified lpn can provide a range of patient care dealing with routine nursing tasks ( assisting patients to bathe , to go the bathroom , and in physical therapy ) and patient monitoring ( charting changes and collecting test samples ) . in quebec , lpns can also start  unmedicated  intravenous ( iv ) therapy , perform minor procedures , change dressings , and other similar tasks under the supervision of an rn or physician . as the complexity of nursing care augments exponentially , along with the acuity of patients ' medical disorders , the working relationship between registered nurses ( rns ) and lpns , specifically interprofessional collaboration ( ipc ) , is a decisive factor in nursing care , one that significantly influences the quality of care [ 57 ] . many factors intertwine to modulate ipcs within different systems : the professional system ( different rn and lpn scopes of practice ) , the organizational system ( leadership styles ) , the interpersonal system ( rn - lpn interactions ) , and the personal system ( personal values , attitudes , etc . ) [ 811 ] . in this study , we aimed to address the organizational and interpersonal determinants of ipcs between rns and lpns in quebec , a province of canada as well as the professional factors affecting ipcs . in the french - speaking province of quebec , the professional body covering lpns ( infirmier(re ) auxiliaire ) , ordre des infirmires et infirmiers auxiliaires du qubec ( oiiaq : the quebec order of licensed practical nurses ) , has a membership of more than 23,500 . registered nurses are covered under a separate association , ordre des inifmires et infirmiers du qubec ( oiiq : the quebec order of nurses ) . in 2003 , with the adoption of bill 90 , the lpn 's scope of practice , as well as that of the rn , was substantially expanded to facilitate greater lpn contribution to patient assessments and therapeutic nursing plans ( tnp ) , more frequently referred to a nursing care plans outside of quebec [ 12 , 13 ] .   additionally , this new regulation , which resulted from collaborative initiatives between the professional associations ( oiiq and oiiaq ) , authorized lpns to undertake a greater role in clinical activities , such as , administering normal saline intravenous therapy and nursing care to respirator - dependent patients . in light of these major changes in the scope of practice , an in - depth look at rn - lpn collaborative interactions and their shared ownership over patient care and nursing interventions is imperative [ 14 , 15 ] . in fact , rn - lpn collaborations at the bedside are essentially an interpersonal process : during daily interactions both professionals are emotionally engaged with each other , hence , both must regulate their emotions ( e.g. , trust , frustration ) in order to work harmoniously for the benefit of their patients [ 1618 ] . the process of regulating emotions has been conceptualized as  emotional labour  . within the field of organizational sociology and psychology , emotional labour has developed into a unique domain of research looking at the labour or the energy that workers expend to modulate their workplace emotions during encounters with coworkers , managers , and the recipients of their services [ 20 , 21 ] . nonetheless , within this domain , the emotional labour underpinning rn - lpn interactions has gone relatively unexplored in the nursing literature . according to gray and smith , emotional labour has not been extensively studied due to the fact that the emotions accompanying healthcare work are often silenced by the nursing staff themselves , in part , because of the espoused value of altruism inherent in nursing care . consequently , this study 's originality resides in its description of the multiple factors that influence ipcs between rns and lpns and the relatively - undocumented emotional processes deployed by lpns in their interactions with rns . study questions examined : ( a ) what is the nature of the rn - lpns interactions ? ( b ) what interpersonal and organisational factors facilitate or hinder collaborative interactions ? ( c ) what is the emotional labour performed by lpns during interactions with rns ?   in the first part of this paper , a concise literature review of ipcs between rns and lpns is discussed within the context of the influencing factors of two systems in particular , organizational and interpersonal systems . the literature review concludes with selective readings focused on the emotional labours underpinning ipc . in the second part , the results of a  paper - and - pencil  questionnaire administered to 309 quebec lpns during their 2008 annual congress is presented and discussed . miller and her colleagues   surmised that rns and lpns form a collegiality , a cohesive community of caring professionals , based on their professional identity and intergroup dynamics . more significantly , hallin and danielson   argue that rns perceive their work environment as stimulating when they are not constrained by workload and , consequently , have time to mentor licensed nursing - support staff towards optimal nursing care . unruh ( 2003 ) also contends that rn - lpn collaborations lessen an rn 's workload even with the additional task of lpn supervision . certainly , rns and lpns share common disciplinary approaches to care but at different levels , due to their differential educational backgrounds . incompatibility between rns and lpns often takes root in role ambiguity , confusion related to the day - to - day application of their unique roles , and differential social status within the organizational hierarchy [ 2730 ] .   in a qualitative study examining rn - lpn collaborations in wound care , huynh and nadon   observed that rn - lpn collaborative interactions , at the microlevel , are influenced by mutual trust . both professionals must manage their emotions ( i.e. , trust or distrust towards the other ) while balancing respect for their colleague 's professional role ( i.e. , rn or lpn ) against an individualized trust for the professional as a person . as aforementioned , collaboration as an interpersonal process is influenced by multiple factors operating within several systems : organizational , professional , interpersonal , and personal . based on the data from the literature , organizational factors that impact on ipcs include nursing leadership [ 32 , 33 ] and organizational culture .   the first factor , effective nursing leadership , is said to exist when high - level nursing administrators and mid - level nurse managers encourage rns and licensed support staff to communicate openly about the understandings and misunderstandings encountered during mundane care - giving activities , to engage in collective problem identification and resolution , and to strive continuously to build collaborative teamwork practices [ 33 , 35 , 36 ] . moreover , inclusive nursing leadership is indicated by the consistent presence of nurse managers at the unit level , coupled with a demonstration of patience , empathetic listening and respect for the entrenched habits of the frontline nursing - support staff , as well as managerial skill in allocating equitable workloads among the nursing staff [ 6 , 3739 ] . concurrent to this , in examining the second organizational factor , upenieks and her colleagues   showed that an organizational culture which empowers nursing staff to initiate innovations in the delivery of nursing care ( e.g. , bedside nursing rounds similar to medical rounds ) also leads to increased communication between nurses and nursing assistants . similarly , an organization that promotes a culture of patient safety also witnesses optimal collaboration among frontline nursing staff ( i.e. , rns , lpns ) . in terms of institutional supports ( i.e. , the third organizational factor ) , well - established and accessible organizational structures ( e.g. , regular team meetings ) , and oft - used channels of communications ( e.g. , billboard for informal and formal memos ) were found to contribute to interprofessional collaboration [ 42 , 43 ] . trust and respect , aspects emanating from the interpersonal system , have consistently emerged in the literature as the emotional factors most influencing the nature of the interactions among health professionals in general and , more specifically , between nurses and nursing support staff [ 37 , 41 , 42 , 4451 ] . based on this mutual trust , rns and lpns exchange patient information and feel empowered to actively seek out and provide constructive feedback to each other . respect , as an interpersonal factor , was found to be one of the key determinants of rn - lpn collaborative interactions [ 37 , 53 ] . respect is evidenced by the reciprocal recognition of coworkers ' work experiences and competencies , and is accompanied by active listening , reflective comments , careful consideration , and empathic attention to the other person 's inputs vis -  - vis a patient 's health status [ 39 , 46 , 54 ] . this being said , within the context of overworked staff , due in large part to the chronic nursing shortage and prescribed organizational policies aimed at maximal productivity , the hectic pace of day - to - day nursing care does not lend itself to the fostering of the positive emotions critical for ipc : trust and respect . yet incongruously , rns and lpns are required to display these unfelt emotions towards their colleagues . the invisible emotional labour of having to display appropriate workplace emotions ( e.g. , respect , trust ) while suppressing negative emotions ( e.g. , anger , frustration ) may contribute to emotional and cognitive dissonance [ 17 , 48 , 56 , 57 ] and , potentially , emotional exhaustion and burnout [ 5862 ] . emotional management in the workplace or , more specifically , emotional labour was first theorized by hochschild . emotional labour  refers to workers ' expenditure of energy in suppressing and/or substantially changing their emotions , in compliance with organizationally defined rules and regulations , in order to display feelings that convey to others a sense of being cared for [ 63 , 64 ] . as an internal personal process , emotional labour is conceptually distinct from the concept of emotional support , which is provided to patients as an essential and fundamental element of nursing care .   within the nursing literature , emotional labour is comprised of two processes : the suppression of negative emotions ( e.g. , frustration , anger ) and the expression of unfelt emotions ( e.g. , respect , trust ) that are deemed to be workplace appropriate . at present , there is a dearth of knowledge about healthcare workers ' and the emotional labours inherent in collaborative endeavours with colleagues : particularly , those experienced by staff in lower hierarchical positions [ 16 , 22 ] . during the 2008 oiiaq annual congress , a survey entitled  the winning experience of collaboration between rns and lpns  was administered , with technical support and assistance from the oiiq , to 309 lpns . the survey 's design employed convenience sampling , a nonprobability sampling technique ; no incentive was offered to the lpns in exchange for their participation . however , different outreach strategies were utilized to maximize the response rate : regular intercom messages throughout the congress reminded the lpns to complete the survey and researchers collected the questionnaires at the door . the questionnaire was developed based on a literature review that focused specifically on the emotions experienced by nursing support staff during their interactions with colleagues and nurse supervisors [ 53 , 6769 ] . findings from three studies suggest that during a delegation process , nursing support staff experience a multitude of conflicting emotions , negative and positive , that affect the nature of their future interactions with the rn in question . thus , the researchers worked collectively on the wording of the questionnaire to ensure clarity and consistency based on the systematic application of an instrument appraisal list ,  as defined by fowler and cosenza . due to time constraints , the questionnaire consisted of 5 questions querying lpns on their experiences of noncollaborative and collaborative interactions with rns , their emotions resulting from these interactions , and their perceptions regarding the interactions of the rn . the lpns were given the choice of selecting from a list of answers that fit their thoughts or of developing their own responses  an open and closed format questionnaire . ( a copy of the questionnaire can be obtained by contacting the lead author ) . the first , the quantitative phase , served to compile and document the frequency of similar responses . in the second , the qualitative phase , data interpretation was undertaken using an initial list of template codes determined by the research team but based on the literature review ; for example , template codes included determinants ( interpersonal , organizational ) and emotions ( negative and positive ) , and so forth . new codes that emerged during the coding process were noted by the individual researchers ; inclusion of new codes was then discussed among the team members . some of the new codes that were retained included auto - determination and pride , which were subsequently collapsed into the emergent theme of professional identity . data ambiguity ( i.e. , where text segments were coded differently ) was also debated in order to reach a consensus . once completed , the codes sharing common elements were merged to form the following themes : factors contributing to ipcs , professional identity , and the emotional labour underpinning lpn - rn interactions ( see figure 1 ) . an audit trail was kept of the rational for collapsing specific codes into themes and of the selected citations used to constructing the themes , see table 1 . the internal validity of this study relied on the triangulation of qualitative and quantitative data . for example , quantitative data indicated that 80 per cent of lpns believe that their interactions with rns are of a collaborative nature ; this concurred with the qualitative data , in which the same lpns had described the collaborative interactions step - by - step . the lead author and the research assistant independently coded all the lpns ' written answers . member checking was done by validating the preliminary results of the survey with the same population of lpns who had completed the questionnaire . a majority of study participants , 80 per cent ( n : 214 of responding lpns out of 267 ) , confirmed that they collaborated with rns daily ; only 14 per cent indicated no collaboration . a few ( n : 3 lpns ) indicated collaborating with specific rns but not others ; in terms of the latter , this was attributed to a lack of experience on the part of the rn  generally a young newly graduated rn . the primary interpersonal factor promoting ipc , as indicated by 63 per cent of the lpn respondents , was an rn 's respect for their patient assessments . another positive factor preceding ipc , as perceived by 28 per cent , was rn 's actions in terms of the solicitation of and active listening to their assessment of a patient 's status . conversely , 62 per cent pointed out that the tension between them and rns was rooted , in the lpn 's perception , to an inappropriate volume of delegated acts ( i.e. , too much or too little ) . moreover , the nature of the delegated acts , when viewed as  dirty work ( e.g. , changing soiled undergarments ) , was also perceived to inhibit future collaborative interactions .   although the compilation of lpn answers did not yield a dominant trend , the most common organizational factors facilitating ipcs were leadership style , teamwork ( as the primary care delivery mode ) , and , finally , the equitable distribution of workload among both rns and lpns . indeed a significant percentage ( 40 per cent ) of lpns attributed a positive work environment , one facilitating ipcs , to the inclusive and compassionate leadership exemplified by the head nurses or their assistants ; these leaders served not only as a source of professional and personal support but also as role models for collaborative interactions . unsurprisingly , 16 per cent attributed their limited rn - lpn communications to an organizational factor : time constraints . the questionnaire asked lpns to describe their emotions following collaborative or uncollaborative interactions with rns . after a collaborative interaction , the majority of the lpns ( 68 per cent ) felt valued by their nursing colleagues , 23 per cent expressed happiness , and 4 per cent indicated feelings of professional accomplishment and personal satisfaction . on the other hand , after uncollaborative interactions with rns , 60 per cent of the lpns felt frustrated , 25 per cent discouraged , and 2 per cent saddened , and 1 per cent expressed aversion to any further interaction with the rn in question . while 1 per cent of the lpns chose to distance themselves emotionally ( i.e. , indifference ) to uncollaborative interactions with an rn , 3 per cent decided to be affirmative : attempted to readdress the issue with the rn or brought the matter to the attention of the nurse manager or the union representative . this section examines the themes that emerged from an analysis of the descriptive responses : the organizational and interpersonal factors facilitating the collaboration , professional identity , and emotional labour that underlie collaborative and uncollaborative interactions . most of the lpns defined ipc as an interpersonal process of exploring similar or dissimilar assessments of a patient 's status with an rn and , together , formulating a course of nursing actions . one lpn emphasized :  the perfect and concrete example of collaboration that i can give is when the nurse shares my own ideal of wound care , has the same motivation like me to speed up wound healing ; she follows up on my suggestion about changing wound treatment , she revises with me the wound care plan . inherent in this definition is that ipc , in the delivery of daily nursing - care activities and in terms of equality between rns and lpns , is founded on the concept of  togetherness  . the following quotes also attest to how these two organizational factors ( i.e. , togetherness and equality ) facilitate ipc .  in our palliative unit , i work on an equal basis with the nurse : she has 4 patients so do i ; we help each other in keeping an eye on the other 's patients .  and  i work closely with the nurse in my paediatric unit , one day she gives the medication to the patients , i take the vital signs , the next day , i give the medications and she takes the vital signs , this way we get to know all our young patients . other lpns also believed that collaboration takes place when lpns are able to share their technical and experiential knowledge ( i.e. , the unit work routine ) , as an equal , with newly - graduated rns . another organizational factor that facilitates not only ipc but also the professional development of lpns is an organizational culture that promotes innovative actions ; as exemplified by this quote :  on our unit the lpns are invited by nurses to discuss their patients during team meetings with the doctors and other professionals . they encourage us to try out new initiatives that help the patients and we can become more efficient .    the most prevalent organizational factor was nursing leadership . an rn 's leadership style was deemed to be inclusive when rns explained the rational underlying nursing interventions , encouraged the lpns to initiate innovative actions , and showed their appreciation or work completed . in contrast , the lpns affirmed that an organizational culture promoting individual work impedes collaborative interactions with rns . the most prevalent interpersonal factor expediting ipc was the level of trust rns exhibited towards lpns , as depicted by one lpn :  the young rns often ask for our opinions , they trust our judgement and we are happy to be their eyes to assess the patients for them .  the second most common interpersonal factor mentioned by the lpns was the respect conveyed by rns towards lpns by means of compliments , as illustrated by this quote :  teamwork is also reciprocal respect as when the nurse makes the effort to thank me for taking initiatives in her absence such as one time ; i kept a closer eye on the resident and reported his worsening status to the doctor . written narratives from the lpns described their workplace self - identity as that of a professional , as evidenced by this quote : i have my own professional license ; i always substantiate my nursing actions with my nursing knowledge , i know that i have to be always accountable for every action that i undertook .  at the interpersonal micro level , lpns believe that their contribution to the nursing team is significant . one lpn stated :  
  as a health worker , sometimes , i feel at loss at all the suffering around because there are a lot of patients being abandoned by family members to die , but being an lpn and a member of my strong nursing team , i got a chance to offer some last comfort to one dying patient and also because the other rns help me with my other chores ; that day i walked out of the hospital prouder thanks to my team ,  my nurses  who really recognized my value as an lpn . as a health worker , sometimes , i feel at loss at all the suffering around because there are a lot of patients being abandoned by family members to die , but being an lpn and a member of my strong nursing team , i got a chance to offer some last comfort to one dying patient and also because the other rns help me with my other chores ; that day i walked out of the hospital prouder thanks to my team ,  my nurses  who really recognized my value as an lpn . this professional self - identity was strengthened even further with the advent and clinical application of bill 90 , the professional law that expanded the lpn 's scope of practice . a large proportion of the lpns ' written answers denoted professional pride in their work : assessing wound status , discussing with rns , and contributing to the elaboration of wound - treatment plans as well as to a positive outcome ( i.e. , wound healing ) . other lpns indicated that these newly acquired skills in wound care added to their sense of personal satisfaction at work . on the other hand , lpns ' increased professional identity as a social group , distinct from rns , has had some unintended effects ; such as the unconscious application of the social distancing strategy , often using negativism to distinguish themselves as a group distinctive from rns , as demonstrated by the following quote :  some nurses do not care what i say to them about the patients ; they just like to sit and chat all day at the nursing station among themselves . several lpns described the intense but internal , thus invisible , effort they had exerted in managing their emotions ( i.e. , to perform emotional labour ) in order to suppress negative feelings following unproductive encounters with rns . surprisingly , the lpns rarely indicated employing the strategy of surface acting ( i.e. , expressing an unfelt emotion of respect ) during instances of disagreement with an rn . conversely , some of the lpns ' negative remarks about rns not only served to differentiate themselves from rns as a group , but also to suppress ( by redirecting ) their feelings of being devalued and belittled after uncollaborative interactions . i reported repeatedly to the nurse that the patient 's status is getting worse , still nothing was done ; it was as if my voice is inaudible , my assessment and me as lpn are worth nothing . one time , one young and inexperienced nurse refused to believe that the patient 's in a lot of pain , i had to keep my calm and discussed patiently with her again and again before she agreed to medicate the patient . an analysis of the numerous accounts of emotional labour experienced by the lpns during ipcs underscored the fact that lpns who possess a strong professional identity , accumulated as a result of many years of practice , are more likely to regulate their emotions in order to transcend conflicts with rns . one lpn argued with dignity and passion : 
  working on this unit for a long time , i have made a few mistakes but i also have a lot of experience as an lpn , a professional ; so sometimes i refuse to take  no  from the nurse . she has more years at school than me but i think that when we talk rationally together we can come to an agreement calmly for the sake of our patient and not to see whether me or she is right . i have made a few mistakes but i also have a lot of experience as an lpn , a professional ; so sometimes i refuse to take  no  from the nurse . she has more years at school than me but i think that when we talk rationally together we can come to an agreement calmly for the sake of our patient and not to see whether me or she is right . the authors recognise that the study has several limitations . the first emanates from the fact that a self - report method , as used in this study , means the results are subject to a positive self - representation bias and limited by one - sided view : the lpn perspective . the title of the questionnaire ,  the winning experience of collaboration between rns and lpns  , might have inadvertently directed the lpns to view rn - lpn collaborations in positive terms , hence have influenced their responses . nonetheless , one of the questions invited lpns to describe uncollaborative interactions with rns , to delineate the determinants of uncollaborative interactions and the impact on their emotions . finally , the fact that the questionnaire was not field tested could imply a reduced confidence in its face validity and quantitative findings . however , as mentioned previously , this risk was mitigated by having the research team carry out triangulation of both quantitative and qualitative findings to substantiate emergent themes . the first of which responds positively to our first research question : rn - lpn interactions are of a collaborative nature . this fact , or least as the intended goal of the ordre des infirmires et infirmiers auxiliaires du qubec , was corroborated by a statement made by the oiiaq 's president in an open letter to quebec 's general population . in the spirit of encouraging a continuous and constructive dialogue between rns and lpns , below , we discuss two of the main ipc - facilitating factors and the emotional labour underpinning uncollaborative interactions emanating from this study . inclusive nursing leadership was found , in this study , to be the main organizational factor facilitating ipc . in their study of teamwork in nursing homes , wicke et al .   found that the junior nurse managers believe that the accessibility of the  matron  ( the equivalent of senior - level nurse manager ) in dealing with any management problems was vital to efficient and cohesive teamwork . this is also consistent with the present literature , in that , good nursing leadership at the executive and unit levels is seen to contribute to the maintenance of an organizational culture that is empowering to nursing staff . the lpns in this study also emphasized equitable workload - distribution as an organizational factor that enhances ipcs . this notion of equity does not mean that rns and lpns should have the same number of patients ( as mentioned by one lpn in the previous section ) . according to several lpn - participants , and affirmed by vogelsmeier 's findings , equity or fairness constitutes an essential aspect of inclusive leadership  defined as one in which workload is distributed according to each individual 's ( rn and lpn ) professional competences and in which feedback on this issue ( workload ) is valued . in contrast with kenney 's   findings that trust is the outcome of rn - lpn interactions , the lpn - participants asserted that trust is itself the most crucial interpersonal factor leading to rather than an outcome of ipc . in concordance with other studies , the lpns affirmed that trust is personalized : the lpns trusted some rns and not others based on past experiences with the rn in question and their perceptions of the rn 's job - related competencies [ 46 , 75 ] . the literature is replete with studies that look at workplace conflicts among nursing staff and between nurses and other health professionals through the lens of communication theories [ 76 , 77 ] ; parallel to this , emotional labour represents an alternative theoretical perspective , one that brings to the forefront the invisible emotional work that the nursing staff ( i.e. , rns and lpns ) undertake in their daily interactions with nursing colleagues and other health professionals . in fact , our findings point to the fact that ipc has two facets : instrumental and emotional . instrumental ipc is the clinical application of the 5r principles : right lpn , right task , right circumstance ( i.e. , does the complexity of task match the competency of the lpn and the availability of bedside clinical teaching ) , right communication or directives , and right supervision as specified by the relevant professional body . emotional ipc is the process whereby rns respectfully entrust nursing interventions to lpns and empowering them to discuss any disagreements in patient assessments and nursing care plans . supporting this , a small body of literature has consistently documented the close link between a worker 's inferior social status , relative to the rn 's , with the performance of emotional labour as a means of preserving dignity in the workplace [ 64 , 79 ] . this study illuminates the emotional labour underpinning ipcs between rns and lpns . from the standpoint of a lower hierarchical status in the workplace , the lpns in this study called attention to the emotional labour underlining their interactions with rns ; this is not dissimilar to the phenomenon whereby nurses manage their emotions in conflicting interactions with physicians . two further issues worthy of mention include the perspective , as expressed by the lpns , that the lpn and rn roles are interchangeable ( as illustrated by the first two quotes in section 5.2.1 ) and the fact that the majority of lpns are women . although , from the lpn perspectives , some nursing activities such as taking vital signs and administering medication , and so forth , can be performed by either the lpn or rn , the global assessment of a patient 's status ( i.e. , determining whether a patient needs any further medical interventions from a nursing perspective ) remains the ultimate responsibility of the rn , as aptly illustrated by the quote  the lpn are the eyes of the rn .    the predominantly female character of the lpn profession and the fact that emotional labour is perceived to be intrinsically female , a fact many women are conscious of , may in fact contribute to a desire to suppress emotional labour , thereby contributing to its invisibility . further , resignation at having little influence with which to challenge the existing social order , a status differential associated with asymmetrical power relationship , may also contribute to the invisibility of emotional labour . it is not our intention to present an overidealized image of lpns , but to recognise their working conditions and to identify factors that could improve the working environment . historically , lpns have been beleaguered with low status within the hierarchy of healthcare organizations ; consequently , the voicing of their experiences as a distinctive group of healthcare professionals is rarely heard . concurrent to this , and within the context of the rising cost of health care , chronic shortages in the rn workforce , and the expansion of the lpn 's scope of practice ( as well as that of rns ) , lpns have emerged as a distinct social group in their interactions with rns [ 79 , 82 ] .   in choosing to look at the emotional aspects of rn - lpn interactions , this study highlights the invisible emotional labours experienced by lpns and the role of nursing leadership as it contributes to ipcs . this is even more pertinent , particularly to administrators of medical facilities , when juxtaposed with the findings of a large study by duffield et al . . the study examined the roles of rns , lpns , nurse managers , and clinical nurse specialists in 80 medical and surgical units and demonstrates that nurse managers face many great and concurrent challenges , such as , providing a supportive work environment for newly hired staff while simultaneously facilitating professional autonomy for all levels of nursing personnel , among a number of other challenges . indeed , nurse managers are called upon not only to empower ( i.e. , guide , coach ) nursing staff to carry out nursing care activities ( e.g. , wound care ) to the highest standard , in accordance with their competencies and knowledge [ 84 , 85 ] , but also to recognize the importance of the emotional labour performed by their staff during encounters with colleagues and patients . building on the findings of this study , further research is required to better understand the perspectives of both rns and lpns in terms of their collaborative and noncollaborative interactions and the emotional labour underpinning these interactions . quasiexperimental studies designed to examine the effects of in - house training programs , that encompasse emotional labour , the frequency and quality of rn - lpn collaborative interactions , and , ultimately , the quality of patient care , are also required . at the educational policy level , the authors recommend that emotional labour as an important concept , albeit an ill - understood one , be integrated into the curriculum of prelicensure rn and lpn programmes . the oiiaq reviewed the questions , created the questionnaire 's graphical design , and authorized its distribution to the lpns attending its annual 2008 congress . all participants were assured of confidentiality , which was further reinforced by the anonymity of the questionnaire .
recognizing the emotional labour underlying interprofessional collaborations ( ipcs ) could be considered a crucial step towards building a cohesive nursing team . 
 although ipcs between registered nurses ( rns ) and licensed practical nurses ( lpns ) have been linked to quality nursing care , little is known about the emotions experienced by lpns during their interactions with rns or those factors that influence ipcs . a questionnaire administered to 309  lpns found that ( 1 ) the professional identity of lpns has evolved into a that of a unique social group 
 ; ( 2 ) lpns define ipc as an interpersonal process of exploring similar or dissimilar assessments of a patient 's status with rns and , together , establishing a course of nursing actions ; ( 3 ) the primary organizational factor facilitating ipcs is inclusive nursing leadership ; ( 4 ) the interpersonal factor promoting ipcs is the level of trust rns extend to lpns ; and ( 5 ) an lpn 's emotional labour ( i.e. , internal emotional regulation ) is most tangible during uncollaborative interactions with rns .