Primary Nursing Model

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    I just started on a MedSurg/CVA specialization unit and we are going to be moving to a new unit this summer and changing our speciality to Neuroscience (spinal cord injuries, hemorrhagic & ischemic CVAs, head injuries, etc.) on top of the move, we are also supposedly changing to the "primary nursing model".

    All I know about this is we will have less CNAs and the RNs will be doing most of the care, including bathing, ADLs, toileting, etc. The unit is a 30 bed unit but for now thye plan on only opening up 18 beds for now. The staffing we were told would be 5 nurses (dont know if this counts charge, too), 1 unit secretary and 1 CNA. Any LPN on the floor will "float".

    Our patient/nurse ratio currently is 6:1 with 1 CNA having up to 12 pt. Currently, half to a majority of our pts are ALREADY total care. I'm assuming with pts having more serious conditions, our total care pts will be on the rise, but on the new unit its to be 4 pts to 1 nurse.

    Does anyone here work with the primary nursing model and how does it work out?
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  4. 1
    The Primary Nurse Model was effective back in the 1980's when length of stays were 1-2 weeks, AND there were plenty of nurses around. Believing that continuity of care is important, ONE nurse on day shift followed the patient through the entire stay, because back then, nurses worked 3 shifts. A nurse would work 7-3 5 days a week, Mon-Fri. Ratio was about 3-4 patients per nurse. There were few 12 hour shifts. AND - nurses had full support in the way of LPN's who would administer po meds, change dressings, and provide other important clinical duties; valuable, abundant aides who provided full ADL support, assistance with ambulation, assistance to the BR, full evening care, etc.; transport/orderly services that brought the patient to their tests on time and delivered them back on time; full dietary support in delivering the RIGHT diet, picking up trays, and reporting to the RN intake of the meal on each patient; full housekeeping services that delivered superior cleanliness and always an abundance of needed linens; and materiel management personnel that made sure all supplies to all floors were always available. In those days, RNs truly provided only RN care.

    This is the defintion of, and implementation of, Primary Care Nursing when Primary Care Nursing had everything to support it. I cringe at the thought that you have been told the Primary Care Nursing Model is in effect, because this is NOT valid these days.

    If you truly go down to only 18 patients with 5 RNs (keep in mind RNs call out and you may work with 4 or 3 RNs frequently), this is about 3-4 patients per nurse - on day shift I assume - BUT with a lack of support services I describe above, and less CNAs, I can't see your actual WORKLOAD decreasing. With that level of acuity, you will feel like you are caring for the same amount of patients as you do now, especially because you will have to do the admissions, discharges, and every other interuption to care (pharmacy problems, order problems, etc.) while your patients lack CNA support. You absolutely cannot count on an LPN, because that person will be floated constantly. 1 Unit Secretary does sound good, IF coverage is there from 7a-11p consistently.

    This is a cost cutting strategy that also has some clinical consolidation that the hospital may deem better for that patient population. It may or may not work out for the long run. Hang in there, work with it, and see what happens. If you determine that you are overburdened and worry about your license constantly, you will need to seriously consider moving on to something different.
    BBFRN likes this.
  5. 0
    I just left a job because they changed to primary care. When I started at this hospital we used team leading and had LVNs that did patient care, which worked very well. When we changed to primary care we were supposed to only have 4-5 patients but it was almost always 6 patients. If we has 18 patients of less we could have 3 rns including the charge nurse and 1 unlicensed staff member which was the secretary. This meant that the charge nurse has to take a full patient load as well as charge ( go to charge nurse meeting and staffing). Which resulted in the other nurses not only having to care for this patients including taking patient to bathroom and transporting patient off the unit but also having to care for the charge nurses patients while she gone as well. Our floor was a general medical unit so we have everything from renal and respiratory patients to patients detoxing from alcohol and drugs. So patient acuity changed from day to day and sometimes during the shift. I would leave at the end of the day in tears more ofter than not feeling like a failure because I was so stressed trying to keep up. I hated to leave my coworkers but I knew I was heading for a quick burn out if I didn't. Don't let your self be convinced that primary care we be easier because it is not. It is your facilities was of cutting cost and having less staff.
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    I just left a hospital where I had worked for 18 months. They changed to primary care. When I first stated I would have 8-10 patients and we would have 1 tech to about 10-15 patients. It was hectic and busy I was able to manage. When we changed to primary care we were told we would have 4-5 patients but we almost always had 6. On the floor where I worked the staffing grid showed that for 18 patients we could have 3 rns including the charge nurse and 1 unlicensed staff which was the secretary. This meant that the charge nurse had to take a full patient load as well as charge, go to staffing and charge nurse meetings handle family issues etc. So when the charge nurse was off of the floor the other that left the other 2 nurses to not only take care of their patient and transport patients off of the floor but the charge nurses as well. Lunch breaks almost never happened and when they did you only took 10-15 minutes. I left most days in tears because I was tired, hungry and over stressed. I felt like a failure. I hated to leave my coworkers since we were close but I knew I was heading for burnout. Please don't left your self be convinced that primary care we be easier or better because it will only be more stressful. Primary nursing might have worked ok 20 years ago but not now.
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    Having experience in both primary and team nursing, I would not accept a team position again. Disclaimer: the hospital in which I practiced team nursing was quite possibly the worst on earth, and the hospital in which I practiced primary was among the best, so my opinions are admittedly slanted.

    First my primary nursing experience. A large Level III NICU in a teaching/referral center. We cared for babies for months at a time, often transported from a distance with parents unable to visit on a regular basis. We also had residents who rotated thru our unit on a monthly basis, so our babies needed consistent advocates in the form of nurses who were well-versed in their needs and care. We worked a combination of 8 and 12 hour shifts, and would be assigned to our primary if at all possible, sometimes as a single assignment (when they were critical), and sometimes with 2-4 other patients as they improved and became feeder-growers. The idea was to have a primary nurse on one shift and "associate nurses" on the other shifts so that there was someone at least once a day caring for the baby with intricate knowledge of the child's needs, who would update the care plan, round with the physicians, suggest treatment options and consultations, communicate with PT, OT, social work, discharge planning, plan and provide parent teaching, etc. It was extremely satisfying to follow a baby from admission to discharge, both for the nursing staff and family.

    Now the team nursing unit. It was a post-partum unit with a separately staffed newborn nursery. We all worked 8 hour shifts. On any given shift, the mother would see her RN who did assessments and managed IVs, her LPN who passed meds and did treatments, her CNA who took vs and assisted with ambulation, hygiene and linen changes on stable PP moms, a bath tech who did baths only on fresh post op C-section moms, a dietary aide who passed trays, a nursery nurse who cared for the infant and provided infant care teaching, and a lactation nurse who assisted with breastfeeding. That was 6-7 caregivers on every single shift. As a result, care was terribly fragmented. Hours often passed before news of an elevated temp or B/P made it from the CNA to the PP RN to the nursery RN, meaning that babies were left with moms who were unstable, and/or the nursery RNs were unaware of conditions that warranted septic work ups and isolation of infants. Teaching was haphazard, and often left undone until the last minute when the discharging nurses had to cram it all in.

    Neither system has a lock on good vs bad. In any situation, staffing ratios must be appropriate to patient care needs. 6 patients to 1 nurse is too many, even with LPNs and CNAs. In a primary nursing situation caring for heavily dependent patients, I think 3 would be the max.
    Last edit by Jolie on Jun 6, '08
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  8. 0
    I believe that what is actually being described is total care nursing rather than primary care. I currently work for a facility that does total care and although I believe in the model, it is not working for us right now.
    We have no aides on our unit. We take 24 patients with each RN or LPN responsible for 3-4 patients on dayshift and the charge taking no pts. I find that 3 is generally quite managable, but on a 7 a - 7p shift, with 4 pts I generally am scrambling to get a break by 1:30 and feel lucky to squeeze in a 15 min. break later in the shift. We recently went to computerized charting which seems to take up more time. We do have transport services, so thankfully I am not pushing my own pt to radiology or to the lobby at d/c. Housekeeping tends to be marginal. If my pt is in isolation, as many on our unit are, I can count on the room not being cleaned every day. I empty garbage in all of my rooms at least once or twice a day. We also have a huge storage issue on the ward as dialysis takes up a ton of space so I often am running to the other end of the unit just to get a 2x2.
    I do like that I get a full picture of the pt. Unfortunately, sometimes I don't get to see that picture until late because I am constantly playing catch up.
    I agree with an earlier poster that if the work is being divided b/t 2 RNs you might as well do all care for each of your 5 pts and have the CNA assist with all 10 as far as baths, toileting, etc.


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