Revisiting Team Nursing: Including LPNs in a Shared Care Delivery Model

Team nursing has had a long history and gained popularity during and after WWII. The “Primary Nursing” model would take over in the early 1980s while implementing the new DRG (Diagnosis Related Groups) reimbursement model.

History: Team Versus Primary Nursing

While primary nursing has been the dominant patient care delivery model for decades, the military team nursing model historically has provided greater patient and nurse satisfaction. This is partly because team member roles are clearly understood and well-orchestrated for the overall goal of quality patient care.

The shift towards primary nursing revolved around how hospitalizations changed as the more acutely ill patients would cycle through more rapidly with shorter hospital stays post-DRG implementation.

Reimbursements were driven by “procedures;” thus, providers began shifting from longer hospital stays for patients accommodating lower patient acuities to shorter stays such as same-day surgeries and higher patient acuities.

With this shift, the patients who remained in the hospital were the most seriously ill, demanding the highest level of nursing care and expertise.  

What Happened to the LPN?

With this shift, it was believed that primary nursing with the RN as the patient’s care plan manager and paired alongside a CNA (certified nursing assistant) 1:1 would follow this patient from admission to discharge. LPNs (licensed practical nurses) did not fit this new model. LPNs were not trained to design the care plan, and it was believed their training was not as sophisticated to handle these more acutely ill patients with shorter stays and higher demands.

Unfortunately, as LPNs were laid off and hospitals decided not to hire them, the number of CNAs to be paired with RNs 1:1 never became a reality. The nursing organizations that were innovative in designing the primary nursing model took pride in their design, but its rollout and implementation for the long term never took hold. Thus, the beginning of the nursing shortage became more acute; while some years were not as significant, the recent years post-COVID-19 pandemic reached crisis levels.

Thankfully, there is a glimmer of hope as LPNs are being reconsidered to be part of the nursing team. Beckett’s integrative review conducted during the COVID-19 pandemic found no statistically significant differences in nurse and patient satisfaction between primary and team nursing models. In fact, RNs felt better supported by their LPN peers.

Upskilling Paraprofessionals

As many hospitals utilize CNAs to provide basic patient care, they will also “upskill” these caretakers, boosting their skill sets with training such as conducting glucometer checks, 12 lead ECGs, and other higher-level skills. Taking some of the burden off the RN, the RN is still left with much work to do- such as medication administration and other intensive treatments- while solely overseeing the management of acutely ill patients requiring fast-track care. As military hospitals still employ LPNs espousing the team nursing model, private sector hospitals continue to utilize the primary nursing model half-heartedly while juggling shortfalls of nursing staff.

As paraprofessionals such as CNAs, PCTs (patient care technicians), NTs (nurse technicians), and MTs (medication technicians) assume more care to assist the RN or replace the RN’s role in some healthcare settings, particularly outside of acute care, the LPN is not typically enlisted in these patient care scenarios or environments.

Concerns within acute care, specifically, may have the potential for LPNs to creep into the RN role; thus, RNs will not be as valued by hospitals and will lose their footprint. As more healthcare sectors are unionized, innovative ideas are hindered, while turf battles take precedence over solving patient care delivery.

It can be disheartening to imagine that more effective and efficient ways of delivering patient care could be reimagined, yet old guards stand in the way.

Reconsidering LPNs as Part of the Acute Care Team

LPNs are trained as nurses. RNs have a higher level of training and education, yet their expertise is not used to its fullest ability. RNs are frustrated to see patient care suffer yet are powerless to make a change.

Nursing administrators and leaders need to be challenged to revisit the LPN as part of the nursing team. Just as CNAs and med techs are trained within hospitals, LPNs can be upskilled to be unit-specific and help formulate and solidify the nursing team headed by the RN team leader.

Additionally, moving away from using the term “staffing” and more towards “teams” is more inclusive, less task-oriented, and more patient-centered. This means that the RN, the designer, and the patient care manager can function more effectively when tasks are delegated to team members to meet “team’” goals. 

RNs should work to the top of their licenses, not simply act as functionaries. Utilizing partnerships versus competing for shifts and assignments is more patient-centered while providing greater job satisfaction for the nursing team.

Isn’t it time to reimage, innovate, and act?