What’s happening to patient engagement?
Shifts in who is providing care at the bedside worry this educator
Head cheese, the gelatinous deli meat, is one of my dad’s favorite foods. But after eating a sandwich made with a bad batch of it, my elderly father was admitted to an acute care unit with dehydration, delirium and acute renal failure. During the two weeks he was there, my mom and I visited him frequently, which gave me my first opportunity to see RNs and LPNs working together in acute care.
As the days went by and Mom and I sat at Dad’s bedside, I watched as numerous caregivers came and went. It was extraordinarily confusing to keep track of who was responsible for various aspects of his care. Dad fluctuated on the continuum of stability/instability, which necessitated ongoing shifts between RNs and LPNs. When I would ask the LPN questions about his kidney function or IV medications, she would respond that she did not know and recommend that we talk with Dad’s RN. Most of the RNs refused to share any information, even though my dad had given his permission for the nurses to discuss his care with us. Dad’s care was organized by the tasks that needed to be done and who might be doing them, but there was no sense of any one nurse knowing my dad in a more comprehensive way. And there was no way for us to obtain an overall picture of his treatment and responses to nursing care.
Knowing the patient through hands-on care used to be a major focus for bedside RNs and, according to Patricia Benner in From Novice to Expert, it is crucial for developing competent nursing practice. Changes to staff mix are constraining RNs’ ability to know their patients. Situating RNs as team leaders, focusing primarily on care planning and discharge planning, removes them from the bedside, while LPNs and health-care aides are increasingly positioned as direct caregivers. As an educator, I worry that this model of care will mean that RNs and students in RN programs will have less access to RN mentors with expertise in hands-on care.
Benner’s findings on skill acquisition form one of the foundational elements of the current LPN curriculum in British Columbia, and they also appear in the Canadian Council for Practical Nurse Regulators document Becoming a Licensed Practical Nurse in Canada: Requisite Skills and Abilities. However, I question if her findings, which are based on 30-year-old research with post-licensure RNs, fit within the realm of the current shifts in staff mix (or can, in fact, even be appropriately applied to post-licensure LPNs). The competency levels Benner refers to are contextually embedded in the RN experience. I believe that shifting care contexts necessitates further research into how the various nursing groups acquire expertise.
It is time for RNs to question the current evidence being used to justify shifts in the composition of nursing teams. As well, it is crucial that they voice their concerns about how RNs learn and teach nursing, question how best to support the development of nursing expertise, and engage in research that examines nursing teams in acute care. The division of labour created by assigning care tasks to various health-care providers is shifting how nursing expertise is developed. Attention must be given to the impact of this shift on patients and families and on our understandings of nursing care.