What does "primary care" mean?

[Rn4life27]

My hospital is thinking of getting rid of CNA's and go to primary care. What does that mean exactly? If it means what I think it means, it means we are in for PURE HELL!!

[SGroRN87]

So here is what a typical 7-3 day on my medical/surgical oncology unit goes (with primary nursing) for 4 patients

6:30-7 review patient charts, orders, labs, eMAR

7-7:30 listen to report from night shift

7:30-8

[SGroRN87]

Sorry!!! I got cut off...

7:30-8:30 assess patients and get vital signs

8:30-9:30 AM med pass

9:30-12:30 AM care, start blood products, check orders, round with docs

12:30-1:30 vital signs, meds, etc.

1:30-2:30 charting, take off more orders

2:30-3 tape report

As you will notice there is no lunch break in here... In addition, add another hour for a patient that goes bad and needs transferred which frequently happens on our unit.

There is no one else to answer call lights, which is a problem during report.

[applewhitern, BSN, RN]

SGro, you forgot to add in helping feed patient's their breakfast and lunch, which also entails pulling them up in bed to get them ready to eat. Just saying......

[SGroRN87]

Yes that too... It's all of those little things we don't consider...

[BlueDevil,DNP, DNP, RN]

I always preferred primary care nursing. Back in my day I did primary care nursing for 6 patients on a med teaching unit for HIV patients when you still had to gown up in bio hazard gear as if you wear making a moon landing. It was the toughest job I ever loved. I enjoyed it, and the care was better. You kids don't know how easy you have it these days.

[edmia, BSN, RN]

See, this is a very short-sighted, and in my opinion, unprofessional, view. Think of all the things a well-educated, perceptive nurse can learn while doing a bed bath. Your conversation can range to who else is in the home, who does the cooking, how many steps to get in the front door, and how will you get to follow-up appointments, for example. Say, did you know that recent research indicates that the answers to those very four simple questions are huge predictors of readmission?

And you can observe bruising or skin tears and ask about abuse. You can ask about medication and treatment plan adherence. You can find out about fears and false hopes. You can look at real range of motion, sensory deficits, joint impairments, cognition... if you care.

As to feeding, who better than the registered nurse to fully evaluate swallow and pocketing and vallecular pooling (by asking for a vocalization-- does the voice sound wet?)? And see whether calories are being consumed can give you hints about endurance, wound healing, and suchlike. Ask whether there's a full larder at home, a functioning kitchen or the ability to use one, or whether it's just common crackers and milk most days.

Or you can see these as mere tasks on a par with, oh, mopping the floor, and abrogate your responsibility under the ANA Scope and Standards of Nursing Practice. Your call.

That sounds wonderful GrnTea, except it is not realistic in today's healthcare environment. For a med-surg RN to he able to provide the care you describe, the patient load can't be more than 3. 4 maybe if the patients are truly uncomplicated med-surg.

It is not unprofessional, it's reality.

In the ICU where we essentially do primary care, it is at times impossible to get this done for 2 patients. It has nothing to do with how good a nurse you are, it has to do with the insane amount of tasks that are piled onto a nurse's list of responsibilities daily.

I often get to work to find yet another checklist I must fill out to comply with someone's idea of effective care. Plus take care of being charge nurse, take care of staffing, cleaning up because people are absolute slobs, calling transport because I've been waiting with my patient hooked up to portables for 20 minutes, paging interns who haven't entered the orders I need, running to pharmacy because the freaking Pyxis isn't stocked with our basic meds, etc. My patient? Well, I'd love to be able to put them first and most of the things I run around doing are under the guise of this premise, but really? I often don't have time to talk to them.

Sadly, I prefer my patients intubated and sedated because then I have time to do it all.

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[edmia, BSN, RN]

God bless you. Seriously. Ten minutes in that environment and I'd stop wasting meds and start diverting.

LOL! Just reading that description made me anxious! Thanks for the comic relief.

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[Morainey, BSN, RN]

Our hospital has been toying with the idea of primary nursing, no forward movement yet. This thread has certainly been very eye-opening though.

[julz68]

On my unit, they do have 2 extra RNs on day shift called "support nurses" whose only jobs are to rove the floor and help where needed. They do what the CNAs used to do, except that they also help pass meds for other RNs if they get behind, start IVs, do procedures/dressing changes, help with admits/discharges, etc.

I work nights and we don't get support nurses. I'm totally jealous that day shift get the extra, very much needed help. I really wish we could have at least one support nurse for at least the 1900-2300 time frame OR a CNA. That seems to be the night shift's busiest time.

The support nurse's shift is from 0600-1830, so at least night shift gets one hour of extra help from 0600-0730, so we can finish up morning med pass and have uninterrupted SBAR.

If I had it my way though, I would much rather go back to team nursing with CNAs. Maybe someday....

#wishfulthinking

[kalevra, BSN, RN]

Welcome to my world. I miss CNAs

[Good Morning, Gil]

I think it means what you think it means lol. Hopefully, though, they lower your ratios; if they don't do that, then yes, indeed, getting your work done will be virtually impossible. We do total care in my ICU with 2 patients, and even that can be challenging at times when you have somebody getting scheduled lactulose for hepatic encephalopathy crawling all over the bed, pooping every few hours, and a critical patient who you just admitted that has a ton going on, who is also pooping often and weighs 300 pounds, for instance, oh, and is also on an insulin drip on contact precautions with concerned family asking you into the room every few minutes. (This is just an example, not actual patients I've taken care of, though it's not uncommon to have an assignment like this).

So, if you work on the floor and have 6 patients as both the RN and CNA, 2 of which are total care, dependent, and 1 of which gets up to use the restroom frequently d/t lasix or a UTI, then, yes, your job is about to be not that fun lol. Hopefully, they'll lower the ratios to 1:4 or something reasonable. What they are doing is not wise as it is cheaper to hire CNAs then it is to lower the ratio for RN's (if they don't lower your ratio somewhat, then it's probably not possible to do the job well without more patients falling, etc).

[Good Morning, Gil]

What GrnTea said. Except you travel a lot in ICU. I travel almost every day with one of my patients (sometimes both) and can be gone for 2 hours at a time with one of my patients depending on the procedure (and then have to come back and do all of the orders that were written for my other patient). Interventional radiology, hyperbarics, and red tag scans take about this long. Plus, the time involved getting your patient ready for transport if they have tubes everywhere, coordinating RT, etc.

I would imagine there would be less travel in a small community hospital ICU, lower acuity there, and less places to travel. I did clinical in a small hospital ICU during school, and it was a lower stress, more downtime kind of environment. This is just based on a single experience, however; I'm sure it's different everywhere.