[jjjoy]

There's much talk of the nursing model versus the medical model but I'm thinking we need an acute care nursing model (if there is one, forgive me! and please lead to me to the appropriate reference!!!)

One thought goes that the medical model is about diagnosing disease processes/injuries and to treat that disease/injury whereas the nursing model is about helping a patient deal both physically and emotionally with the illness process.

Anyway, how about a model specific for acute care nursing? That model would include prioritizing patient needs. For example, acute care nursing involves the constant re-prioritizing of changing patient needs to regularly assess and monitor patient status, to administer ordered treatments, to prevent complications or a worsening of negative conditions (including pain), and to achieve and maintain the highest quality of life (including functional status and mental health). I'm probably missing something there but as I read old posts on nursing models and theories, many argue that they help students organize their thoughts and understand their role as a nurse.

Yet, in acute care, the many well documented needs and interventions such as turning Q2, therapeutic listening, assisting the patient to ambulate either get shifted to the CNA or rushed due to competing demands. Eighty percent of school care plans turns out to be only 10% of what the floor RN actually does. The other 90% is run around trying to assess, monitor, document, administer medications, etc in a timely manner.

Why, then, doesn't a larger percentage of nursing education cover this aspect of care? In our med-surg book, paragraphs were devoted to the pathophys and treatments for a zillion different conditions. Another couple of paragraphs would be on a potentional nursing intervetions (which always included things like potential for skin breakdown and altered body image) and possible nursing tasks and procedures (such as inserting an NG tube or keeping the patient NPO). Absolutely nothing on what do when you've got several patients each with several nursing needs and only one nurse to do it all.

So if you had a nursing model specific to acute care, then this very important aspect of nursing care (prioritizing) might not be glossed over in school.

Thoughts??

[pickledpepperRN]

I think it is more important to work for nurses to be able to provide needed nursing care as we were taught in school.
Employers who make a profit by charging for nursing care then skimping on that care should not be accomidated.
I will not accept having to choose whether to save a life or to turn my other patients.
These acute care facilities don't need fountains, $50,000.00 charting systems that make it harder, lobbys like five star hotels, and patients lying unbathed in a dirty bed.

Isn't this the model we use?

STANDARDS OF COMPETENT PERFORMANCE

A registered nurse shall be considered to be competent when he/she consistently demonstrates the ability to transfer scientific knowledge from social, biological and physical sciences in applying the nursing process, as
follows:

(1) Formulates a nursing diagnosis through observation of the client's physical condition and behavior, and through interpretation of information obtained from the client and others, including the health team.

(2) Formulates a care plan, in collaboration with the client, which ensures that direct and indirect nursing care
services provide for the client's safety, comfort, hygiene, and protection, and for disease prevention and
restorative measures.

(3) Performs skills essential to the kind of nursing action to be taken, explains the health treatment to the client and family and teaches the client and family how to care for the client's health needs.

(4) Delegates tasks to subordinates based on the legal scopes of practice of the subordinates and on the preparation and capability needed in the tasks to be delegated, and effectively supervises nursing care being given by subordinates.

(5) Evaluates the effectiveness of the care plan through observation of the client's physical condition and behavior, signs and symptoms of illness, and reactions to treatment and through communication with the client and the health team members, and modifies the plan as needed.

(6) Acts as the client's advocate, as circumstances require by initiating action to improve health care or to change decisions or activities which are against the interests or wishes of the client, and by giving the client
the opportunity to make informed decisions about health care before it is provided.

California Nursing Practice Act: http://www.rn.ca.gov/npa/title16.htm#1443.5

[glasgow3]

Originally Posted by jjjoy

There's much talk of the nursing model versus the medical model but I'm thinking we need an acute care nursing model (if there is one, forgive me! and please lead to me to the appropriate reference!!!)



Anyway, how about a model specific for acute care nursing? That model would include prioritizing patient needs. For example, acute care nursing involves the constant re-prioritizing of changing patient needs to regularly assess and monitor patient status, to administer ordered treatments, to prevent complications or a worsening of negative conditions (including pain), and to achieve and maintain the highest quality of life (including functional status and mental health). I'm probably missing something there but as I read old posts on nursing models and theories, many argue that they help students organize their thoughts and understand their role as a nurse.

Thoughts??

I think you are on to something here. Here is my "take" on the phenomena.

In the academic world nurses are taught to prioritize interventions for a given patient. Call it critical thinking, implementing the nursing process or whatever....the nurse learns what to look for, analyze what they see, decide what they need to do and in what order. In my view not an unreasonable pedagogical approach.

But in acute care, (with the exception of critical care) the nurse does not typically take care of one or even just two patients. In an ideal world, the staff nurse could use what they learned for a single patient and apply those same principles to their actual assignments-----and to a degree that is what they attempt to do.

But unfortunately, with today's staffing/ratios the nurse is often faced with making priorities when in fact there are no good choices-----two things should be done "first" with only a single nurse to do them. Additionally, external forces further pervert the process...for example, a manager reprimands the nurse for not bringing visitors soft drinks resulting in a complaint while the nurse chose to perform interventions which were clearly of a higher priority instead.

I cringe when I see consultants or nurse leaders attempt to "reshape" or "make more efficient" the work of staff nurses by setting up timed schedules for their various daily tasks, as though the environment was that of an assembly line. The nonrecurring events which these folks purposely give a blind eye to (since they don't mesh with their theories) are in fact more the rule than the exception for a typical staff nurse's shift.

[jjjoy]

Originally Posted by spacenurse

I think it is more important to work for nurses to be able to provide needed nursing care as we were taught in school.
Employers who make a profit by charging for nursing care then skimping on that care should not be accomidated.
I will not accept having to choose whether to save a life or to turn my other patients.

But isn't that the reality that nurses are faced with? New grads are chastised to learn "prioritization" asap. A nurse may be able to get everything done without compromising care but to do that takes great speed and ability to juggle competing demands. To go from being new grad who focused on just a few patients with lengthy written out care plans to be able to handle that juggling and keep a mental list of the various changing patient needs is a STEEP curve as nursing school doesn't usually prepare students for that aspect of floor nursing. And so many students want to go straight to specialty areas and others who do work the general floor end up wanting to quit because they can't see how it's possible to give good nursing care with so many competing demands.

[MLOS]

jjjoy, I do think you're on to something here ...

I personally find some of what I was taught in nursing school to be every bit as paternalistic toward patients as "old school" medicine is frequently criticized as having been.

I'd like to see "care plan" changed to "treatment plan." The change in verbage might not seem like a big deal at first blush, but IMO more accurately emphasizes the professional care provided by professional nurses.

If I am understanding the OP correctly, this is a big part of the "reality shock" experienced by new grads.

In my ideal world, nurse-patient ratio everywhere would be 1:4, (maybe 1:6 at night), with every unit also having a "flex" nurse without an assignment every shift to relieve for lunches & breaks, help w/unstable patients & new admissions, etc.

[pickledpepperRN]

The reality now is that nurses are expected to do the impossible.
Of course we have to do the best we can for our patients.
But for the sake of our profession, our patients, and society I think we need to work for a direct care nurse run system in our hospitals and nursing homes.
Isn't their "product" nursing care?

They cannot stay in business without nurses so WE need to act to improve staffing.
We need to work to change the systen so we CAN provide the care as we were taught.

[SharonH, RN]

I must agree with spacenurse. While I understand what you are saying about preparing for the reality of nursing, it sounds like giving in to me. Over the years, I have watched nursing care deteriorate as conditions deteriorated and the focus became solely implementing physician orders versus providing nursing care which was believed to be less important. But it wasn't I tell you. I also watched the results of this decreased focus on nursing care as drug resistant infections have become rampant, patients STILL get pressure ulcers which do prolong hospitalizations and lead to all manner of other complications and patients still get preventable complications of hospitalization like pneumonia, post-op ileus and DVTs. All because in the name of "prioritizing" we focus more on hanging antibiotics instead of walking and turning our patients. Teaching students to focus on being task-oriented neither helps our profession nor the new nurse.

I would much prefer that we continue to fight to improve conditions in the work environment instead of teaching new grads to adapt. Nursing care plans or treatment plans as MLOS terms them are not being implemented to the detriment of patient care. We shouldn't give in.

[jjjoy]

Even with lower ratios, unless assigned to only 1-2 patients, the nurse would still need to prioritize and juggle competing needs, so accounting for that in training isn't "giving in." It doesn't condone putting nurses in situations where it's impossible to give good care.

It could, though, give the new grads a better idea of what is reasonable to handle. As it is, the new grad has no way to determine what is a safe workload. They have no reason not to believe the nurse manager who tells them that they "just need to manage their time better" and "learn to prioritize."

So in addition to teaching about juggling several different patients and their various needs, nursing schools could also teach safe staffing strategies (eg ratios/acuity/staff mix) so that they are well-versed in the administrative angle of staffing and better able to recognize and defend themselves against unsafe staffing.

[pickledpepperRN]

Thank you Sharon.

I worked with a senior nursing student who said that on her previous rotation she was told by the staff nurse and the manager not to do a full assessment. "Just do a focused assessment on the knee that was operated on"
A head to toe examination is not even an assessment. It is the observation and data collection we must do in order to analyze and synthesize all the data and using the scientific knowledge make a nursing diagnosis. A surgery patient with diabetes and COPD requires a different plan of care than one with no secondary diagnosis.

Isn't that what the practice act in your state requires?

So WHY is a student told to deny the patient the nursing process.
See I can tell that even if you don't have time to write a care plan you are planning the care. You want to turn, cough, and deep breathe your patient. To alleviate fear, to teach.

We cannot give up nursing. No wonder they call experienced nurses "troublemakers".