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!!

[Good Morning, Gil]

Julz68, whatever you do, stay where you are and never leave lol. That is unheard of anywhere.

[carolinapooh, BSN, RN]

It was too much! And I heard they were going to make the night shift give full bed baths ***! Come on! So I lasted there a whole 2.5 months feel like a failure but that type of environment is way to demanding.

You weren't a failure. You did the best you could with the circumstances you were given.

The hospital? Now, there's the failure.

[ThePrincessBride, MSN, RN, NP]

Primary care would be a nightmare, and I'm not saying this as a PCA, but as a nursing student. It could work well in ICU with 1:1 patient ratio, but even then, I think it is better to have aide. Also, if the ICU nurse has two patients and one codes, who is going to be able to help with the other patient? You can't leave a patient who is coding to help the other one with toileting issues.

[beckster_01, BSN, RN]

The more time I spend here the more I love my job. When I worked on the floor primary nursing with no pct would MAYBE be possible with 3-4 patients, but a float nurse would make it much more doable. As it is, I would have 4-5 patients, with 2 pct's on days and a float nurse 50% of the time. Nights would be 6 patients and 1 pct.

Primary nursing is far more well suited to ICU care, when it is critical for you to know everything there is about your patient, frequent skin/dressing assessments are required, and you generally have plenty of tasks to do each time you enter the room at any given time.

I do want to validate what grntea was saying though. When I worked the floor one on one time feeding or bathing my patients was such a good oppurtinity for assessment and education that a tech/cna can't do. But if you are going to remove support staff you HAVE to replace them with RNs! My favorite period of time on the floor was when we were extremely short on techs, and nurses were allowed to fill in for them. There is plenty of work for the RN to find, they are highly motivated to help, know where they are most needed, and any task can be delegated. So my take? You should only remove a cna if you replace them with an RN, which won't happen because it is obviously less cost effective.

[jedromey]

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.

You drove home the point! I liked what you said about the readmission predictors. I just had an interview yesterday and the director said they are really trying hard to prevent this from happening, especially with the new CMS penalties looming. May I know which study you are referring to? Can you please share the link? Thanks!

[carolinapooh, BSN, RN]

When I was a civilian RN I worked on a 32 bed medical oncology floor. At night each RN had seven patients most of the time, and the charge RN had four minimum.

There is absolutely no way primary care would work in that setting.

On days, we had as many as five patients, six if someone called out and we couldn't get a float RN (yep, I saw it happen). I never had less than four unless our unit was empty (and it never, ever stayed that way long).

There is absolutely no way primary care could SAFELY work in that setting.

Chemo, blood, replacements, chemo side effects, rapid responses - normal, daily life there. It wasn't unusual to have ALL of those in one assignment for the whole 12 hours. This doesn't count admissions, discharges (and there were days I'd get five and hand off five more, with three of them being new patients - yep, it happened, and it wasn't unusual - did it on nights, too: seven come in, four go out, four new ones come in).

Primary care? HA! Some days I was lucky to do primary nursing! I had my first of sadly many experiences with dehydration headaches and bladder spasms working at that pace - especially on day shift, even with three NCAs.

So it doesn't make me any less the professional to say there are places where it's simply impossible, it's unsafe, and it's actually unfair to the patients. I don't think the tasks are beneath me - on the contrary. Since being back on active duty I came close to blowing my top with a nursing assistant because she was refusing (OMG) to give a DYING PATIENT A PROPER BED BATH, saying she never learned how to do that (BS) and that we didn't do those, we only used the wipes. (And my first thought was, what in the H* does that mean?) I had a teaching session with her - she was going to nursing school at the time - and explained that especially when people were dying, they need to go down their 'list' of things they need to do before they died, and one of the things for this woman was she kept saying she needed a bath before she left - her exact words. We weren't especially busy - I had a couple of meds to pass and there was chemo needing checking - but I said if you go in and start, I'll meet you in there and help you finish. She adamantly refused. Finally I looked at her and said, "If you flat up don't want to do it, just say so - don't lie to me and tell me you weren't taught - I went to a BSN program and we gave each other bed baths."

Zip. I don't think she cared, really. Somehow - SOMEHOW - I kept my cool.

I looked at my watch - did a quick mental rundown of what needed doing, and then did it, with one exception, which I asked for help on and told the other RN why. She was, of course, all for it. We had a tech school student on the floor so I went and asked HER - 'want to help'? She said yes and together the two students and I (she went and got her friend) gave this poor dying woman a bed bath.

(To wave my own flag, the students said they'd NEVER seen nor even heard of a lieutenant, which I was at the time, do this in their short experience - and I told them rank is meaningless a good chunk of the time, first and foremost, I'M A NURSE. If it's in my scope, I do it. I also told them when we were done that they would never forget the appreciation on that poor lady's face, nor the soft 'thank yous' she kept repeating.)

The tasks aren't beneath me. Letting my patients get screwed over because some CEO wants to cut his bottom line? That's well beneath me, and they'd be looking for another RN pretty quick, even if it meant I did telephone triage somewhere. I'd work for a pharmaceutical company before I'd do that - and to me, they're pretty low on the totem pole of respectable employers.

[Penelope_Pitstop, BSN, RN]

You kids don't know how easy you have it these days.

I've only been a nurse for seven years, but the patients I have now on a medical floor would have been in stepdown when I started as a nurse, and the floor patients I had then...well, half of them would be in short term rehab, if that. I had seven to eight patients then because I could - the acuity allowed for it. So could I have primaried for the number of patients I have now with the acuity I had then (plus the prior lack of emphasis on all sorts of crazy documentation)? Absolutely.

[BrandonLPN, LPN]

Well, obviously primary RN nursing would be ideal if employers would staff enough RNs to make it work.

But that is one huge, gargantuan "if"....

Primary care will always be a pipe dream, unless RNs suddenly decide to cut their pay on half in order to make it work. The real debate should be which model of team nursing is best.

[ComeTogether, LPN]

With the exception of nurse-only duties, mind you, what everyone is describing is a day in the life of a typical CNA. Having more work than one can safely handle and being spread so thin you need a Valium when you get home. The difference is CNA's don't get hung out to dry for missing a med pass or another essential responsibility, I realize. Just saying--not all nurses know how hard it is to do what we do.....for less than half the salary. I love it when a RN gets pulled to be a CNA for a 12 hour shift and on the way out says "I have no idea how you do that every day".

Just saying.....love your CNA's (the good ones :-p)

[julz68]

With the exception of nurse-only duties, mind you, what everyone is describing is a day in the life of a typical CNA. Having more work than one can safely handle and being spread so thin you need a Valium when you get home. The difference is CNA's don't get hung out to dry for missing a med pass or another essential responsibility, I realize. Just saying--not all nurses know how hard it is to do what we do.....for less than half the salary. I love it when a RN gets pulled to be a CNA for a 12 hour shift and on the way out says "I have no idea how you do that every day".

Just saying.....love your CNA's (the good ones :-p)

Some RNs do know. I was a CNA for 16 years and know EXACTLY what you are saying.

Once I finished school and started working as an RN, all the CNAs were laid off...

....so there are no CNAs to love.

[ComeTogether, LPN]

I know Julz, thats why I said some :-) Well, you can love them from afar, I guess :) Is your body any better off now that you're an RN? Or not so much with the primary care?

[julz68]

I know Julz thats why I said some :-) Well, you can love them from afar, I guess :) Is your body any better off now that you're an RN? Or not so much with the primary care?[/quote']

I think it is. I have 4-5 patients now. When I was an aide, I was responsible for 36 pts on an ortho floor, which meant almost everyone needed help to the bathroom or turned q2°. And my first few years were in LTC...that was even more back breaking! Ugh.

I always swore that when I became an RN that I would never treat the aides like I had been treated in the past. Now I don't have any! Which is sad, because the pt satisfaction scores have been declining.