Does your facility practice "primary nursing"?
By primary nursing, I mean where each pt is assigned a primary nurse. That nurse has overall responsibility for each pt--oversees the care plan, communicates with physicians and other staff, etc. When the primary nurse isn't there, "associate nurses" (ie whomever is available that day or night) take the pt. But whenever the primary is there, she/he takes that pt.
Our facility has gone to this (though we were kind of doing it before since a lot of it is simply continuity of care and common sense), and we have an issue as night shifters. I don't want to start a day shift vs night shift kind of thing, but here's the deal: we night shifters feel like we cannot be primary nurses.
Here are some of our reasons:
1. We have no active collaboration with any other staff except for respiratory therapy. I have never even seen a PT or OT; I rarely am able to speak with the pt's physician (just whomever is on call, and then only for acute matters at 3am). I can't identify any social worker by name or sight, I don't think I've ever seen any of them. How am I supposed to coordinate care and collaborate with other fields when I never see any of them? Care conferences only take place on days. As a night shift primary nurse, I will never ever participate in a care conference. Neither will I ever attend any meeting between family and social work, the primary physician, hospice, pain team, wound healing team, or palliative care team. All those meetings occur on days.
2. We have little collaboration with family. Maybe we see them for an hour or two. Visiting hours end two hours after my shift starts. How am I supposed to be a "go between" between the family, pt and the other disciplines (including the primary and consulting physicians) if I only have two hours (the busiest two hours of my shift) to even have the potential to see or talk to the family?
3. As primary nurses, at some point during my shift I am supposed to sit down with the pt (and family if possible, especially if the pt is not a/o x3) and discuss the plan of care. I start getting report at 1900. Assessments are due by 2100. All hs meds and care are to be completed by 2200. When am I supposed to do this? 3am? Should I wake up my pts to do this? How about call their family members/DPOMAs to ask for their input? Of course this doesn't work. I rarely am able to do this on nights. By the time I've finished with my more pressing tasks, visiting hours are over, pts are ready to go to slee, and family members do not want phone calls unless the pt's status has changed. Yet we have been told in no uncertain terms that this care plan discussion is an "expectation". Really? But of course no true guidance on how to actually do this.
4. Manthey, who "wrote the book" on Primary Nursing (the one that our managers requested we read, and the book upon which we are basing our primary nursing practice) states that as a rule night shift should not be assigned as primary nurses, mainly for the reasons I have stated above.
So, before my fellow night shifters and I go to our administrators with our concerns and suggestions (basically that day shift be primary nurses, night shift be only associate nurses and maybe try to assume some of the administrative, paperwork heavy tasks of day shift to free them up to do more of the primary nursing stuff), we wanted to know how other facilities with this form of primary nursing in place handles this.
Are night shifters primary nurses where you work? If so, how do you handle the collaboration with other disciplines? What about care conferences?
If not, what tasks and duties have night shift assumed to help free up some day shift time? We don't want to just dump this all on day shift without helping them out in some way. We already do all the MAR checks and stuff the charts. What other tasks could we do to free up their time?
Thanks in advance for the input!
I understand what you are saying. We have always practiced a continuity of care and have never done team nursing. I have never had an LPN pass my meds, for example. I sometimes have an aide, but usually I am responsible for 100% of my pt's care.
As a primary nurse as our facility requires it, each pt is assigned ONE primary nurse. The primary nurse is responsible for initiating the care plan and overseeing the care. He/she is responsible for collaborating with other disciplines to ensure the pt is getting all the appropriate care he/she needs. We are to think of ourselves as somewhat independent practitioners--similar to a physical therapist. We are collaborating in the care on equal footing with the other disciplines. The associate nurse is the nurse who is taking care of the pt when the primary nurse is not working. So on the shifts that I don't work (all day shifts and any of my nights off) the "associate nurse" takes care of the pt. Does that make sense?
As a night shifter, it is difficult to fulfill this role.
Last edit by queenjean on Nov 19, '08