A Push for the Return of Team Nursing in Medical-Surgical and Telemetry/Step-down Units

[Lev]

Welcome to the world of team nursing, where two nurses and a nursing assistant share the burden of a larger assignment but have the advantage of teamwork. As a nursing student and new nurse, I heard about team nursing from some of the more experienced, seasoned nurses. They spoke about team nursing with nostalgia, not because of the larger assignment, but because everyone worked together as a team, because they had too.

I was thinking about team nursing today and its advantages. For one, it is great to have an extra nurse around when you are dealing with a psych patient, even on a non-psychiatric unit. Psychiatric patients and even those without diagnosed psychiatric disorders may practice splitting, which means attempting to turn staff against each other in order to manipulate a particular staff member. One common example of this is when a patient tells a particular nurse that they are much "nicer" or a "better nurse" than their nurse last shift or that the CNA "isn't very friendly." What they are saying may be true, but it could be an attempt to win your favor. Psych patients may also attempt to manipulate staff by making requests and then undoing them. If you call them out on their behavior, they will deny it at times. For example, I had a patient in the ER who had documented psych issues last week. She was very selective about when she spoke or answered my questions. She kept pushing the call bell and when I asked her what she needed, she didn't answer. Finally, after the 3^rd time, she said "I need a blanket." I got her a blanket and spread it out on her, and they she took it off and said "I don't want this." This is an example of classic manipulation. Having another nurse there would help curb these behaviors.

It can also be helpful for patient compliance because a united front is a stronger front. If you patient is insisting on leaving the unit to smoke for example or doesn't want to ambulate in the hall, having two nurses educating the patient about the healthier choice may encourage them to choose the option that is best for them. When the nurse is sharing your assignment and is therefore in close proximity it is easier to get this kind of help and support when you need it.

I think it can also make the shift go much more smoothly. For example, one nurse can focus on doing assessments on the eight, nine, or ten patients assigned to them, while the other nurse can focus solely on passing medications. Nurse #1 who did the assessments will pass off relevant information I.e. abnormal finding in her assessments to Nurse #2 before Nurse #2 starts his med pass. If he gets a phone call, he can safely ignore it and it will go to the other nurse's phone. This can decrease medication errors because the nurse feels less rushed and can focus on the task at hand without interruptions. The CNA can hover between the rooms the nurses have not yet reached to document vital signs and or help patients to the bathroom (to avoid such requests when the nurse comes to pass meds or do an assessment as so commonly happens). An alternative would be the nurses going in together to do assessment, one doing the assessment and the other nurse documenting for her. The nurse doing the assessment would take a quick look at what was documented prior to signing the assessment. This would also help both nurses be informed about each patient's assessment findings.

Having another nurse available can also help nurses deal with the emotional and physical parts of the job. By sharing patients, both nurses feel vested in their assignment. When the CNA is busy in another room, one nurse can call the other to help turn or toilet a patient or even to do wound care. When you need a break or a hug, there is always someone there to back you up and support you.

Team nursing can also be a good way to help new nurses acclimate to nursing once they are off orientation. Being teamed with a more experienced nurse can be a great learning experience. If there is a problem, the more seasoned nurse can step in and offer a solution. If the novice nurse has questions, there is a more experienced colleague close by to answer questions. However, if tasks are divided and the newer nurse is assigned to do the assessments and the more experienced nurse questions her assessments it can create resentment even if her concerns are legitimate. There has to be a great deal of trust in this arrangement.

Team nursing requires trust in another nurse's abilities as well as the ability to get along. A toxic nursing environment that uses team nursing can be detrimental. An industrious CNA make it or break it in primary or team nursing. There would have to be a lot of thought put into the assignment regarding which nurses and CNAs work best together and to make sure skill level is compatible. For example, it would be better to avoid having two nurses fresh off orientation working together.

Team nursing can make shifts go more smoothly by minimizing interruptions and helping patients behave better. It can help with the emotional and physical burdens of the job. To me, the challenges seem easy to overcome and a good tradeoff to reap from the many benefits. Post your thoughts below.

[hollyann12]

We do informal team nursing at my job (GI). It's one of my favorite things about my job--that you're never truly alone. We help each other out. It's never just my patient; it's your patient too. One of us will check the patient in while the other starts the IV and so on. I never felt this level of team work when I worked in the hospital.

[calivianya, BSN, RN]

We did team nursing at my hospital until last week. We didn't have CNAs, but we usually had a resource LPN who was free for anyone to call for help. If I got stuck in one of my patient's rooms for hours, I could call the LPN, who could give my meds for me, turn my patient, etc. If staffing got really bad, they pulled the LPNs out of resource and into assignments to try to avoid giving us all three ICU patients. I really liked team nursing.

I say until last week because all of the LPNs finally got laid off en masse. They couldn't even finish the current week, just boom - go home, you are done. We were already short and getting tripled a lot, but now that we've lost our resources, who were also filling holes by taking assignments if needed... we are going to be in some serious hot water. I am afraid of what the future looks like for my unit without them. It doesn't help that we orient new grads for six months and experienced nurses for 12 weeks, so it's going to be impossible to fill the holes left by axing the LPNs on short notice. It's just a really bad situation.

[RNperdiem, RN]

Team nursing seems to come and go.

The trouble is often meds and assessments and treatments are intertwined, at least in ICU and stepdown. If one nurse is doing assessments, the CNA is taking vital signs, the med nurse could be missing important information. Sometimes it is important to know when not to give the med. The information you need is part of the assessment and vital signs.

[canoehead, BSN, RN]

I'm not a student, and did team nursing back in the day. Everyone ends up knowing a little bit about each patient, but no one knows anyone in depth. No one has ultimate responsibility.

Switching nursing care modalities has been used to gradually decrease nursing care hours. So, we switched from team nursing to primary care, now we're switching back. Let me be the first to predict that it's easier to add a patient to an eight patient load than a four, and blame your more efficient team system. You heard it here first.

[sallyrnrrt, ADN, RN]

Decades ago.....it was very effective, especially in critical care

[automotiveRN67]

Team nursing is a culture. I have worked in quaint little country hospitals (so small the ER and ICU was one unit), to the largest university hospitals (so large we had patients wander off the unit and shoot heroin in the parking lot). It didn't matter which hospital, some naturally adapted team nursing and camaraderie, and some did not. I have seen administration try to force team nursing, in chaotic environments, but that was usually a fail.

The last hospital I worked on the floor, I worked in a 20-bed ICU. Any of the regular nurses on the unit were familiar enough with the patients to jump in and help. Then administration decided to pull/float and short staff on a regular basis. It became a miserable place to work. Too bad.

I do think that a team of RN/LPN/CNA works well, if the staffing is regular, and the patient census is regular. RN-assessment, LPN

-meds/tx, CNA-Basic care and call lights. But, with census and staff in flux, that also tends to fail.

[icuRNmaggie, BSN, RN]

The team nursing model as implemented in my first nursing position in Oncology allowed us to provide outstanding care. The twenty bed unit had two halls. Each hall had a team consisting of an RN, an LPN and an aide. These roles were clearly defined, we took report together and we were a team in the truest sense of the word. Ortho, telemetry and MS had the same roles and routine and so it was not difficult to function in other units when needed. Dayshift had a charge nurse to coordinate discharges and transport to other departments.

The aide was responsible for meals, VS, providing water twice a shift, toileting, HS care and activity orders. The LPN had five lower acuity patients and passed the po meds to all ten patients and worked with the aide providing direct patient care. I was blessed to work with some highly experienced and conscientious LPNs. The RN did everything IV related, all admission assessments, dealt with the physicians, new orders, care plans and cosigned the LPNs charting. An RN assessment was required every 24 hours and the assignment rotated accordingly each shift.

Patients were clean, fed, turned, ambulated, linens were changed daily and skipping am baths or HS care was unthinkable.( HS care meant washing the face and hands and brushing the teeth or dentures. ) Our communication, teamwork and patient care was excellent. We could trust each other. There was never a need to call a rapid response to rescue a patient as there were three of us monitoring the patients on our team.

My university school of nursing required me to work a month of nightshift charge in this hospital as part of my leadership clinical practicum. I was well equipped for this position and never experienced reality shock. I feel that my RN meant more in 1991 than it does today.

The nurses of twenty five years ago would be appalled at what it means to be a patient, or an RN, on a MS unit in 2015.

[automotiveRN67]

I agree with the above. 25 years ago, patients were taken care of like you say. I walk through hospitals today, and I see everybody texting, or standing at the nurses station B$%tching about their assignment.

[icuRNmaggie, BSN, RN]

Primary nursing was intended to elevate the profession according to the research by Linda Aiken and the late Joyce Clifford.

An all BSN staff with a 4:1 ratio, outside of specialty units, was recommended by Aiken. Primary nursing, outside of specialty units, and the academics who support it, have done a real disservice to the profession. My cynical side tells me that our professional organization, and our managers and administrators who sold us primary nursing did it as a cost savings measure and nothing more.

A primary nursing model is required for magnet designation. Hospitals that have a magnet designation- or no magnet designation- have one RN doing the work of two to three people as described above.

We have subsequent research from Linda Aiken that supports California's mandatory ratios, and their effect on outcomes, but it has been largely ignored. This should not come as a surprise to anyone. I have known many CEOs and CFOs who are utterly clueless about how to run a hospital and achieve good outcomes. It is a profit oriented business to them and nothing more. Ditto for the majority of nursing executives who want the same salary and perks.

We are going about this all wrong. We need a similar study on the profitability of each nursing model and the California mandatory ratios, in terms of labor costs, outcomes, mortality, length of stay, infection rates, patient falls and employee injuries.

Healthcare is a highly complex, sometimes highly corrupt, trillion dollar industry of systematic overcharging that needs a complete overhaul. The Nursing profession should be an integral part of managing it's practices and finances.

[DatMurse]

icuRNmaggie said:

The team nursing model as implemented in my first nursing position in Oncology allowed us to provide outstanding care. The twenty bed unit had two halls. Each hall had a team consisting of an RN, an LPN and an aide. These roles were clearly defined, we took report together and we were a team in the truest sense of the word. Ortho, telemetry and MS had the same roles and routine and so it was not difficult to function in other units when needed. Dayshift had a charge nurse to coordinate discharges and transport to other departments.

The aide was responsible for meals, VS, providing water twice a shift, toileting, HS care and activity orders. The LPN had five lower acuity patients and passed the po meds to all ten patients and worked with the aide providing direct patient care. I was blessed to work with some highly experienced and conscientious LPNs. The RN did everything IV related, all admission assessments, dealt with the physicians, new orders, care plans and cosigned the LPNs charting. An RN assessment was required every 24 hours and the assignment rotated accordingly each shift.

Patients were clean, fed, turned, ambulated, linens were changed daily and skipping am baths or HS care was unthinkable.( HS care meant washing the face and hands and brushing the teeth or dentures. ) Our communication, teamwork and patient care was excellent. We could trust each other. There was never a need to call a rapid response to rescue a patient as there were three of us monitoring the patients on our team.

My university school of nursing required me to work a month of nightshift charge in this hospital as part of my leadership clinical practicum. I was well equipped for this position and never experienced reality shock. I feel that my RN meant more in 1991 than it does today.

The nurses of twenty five years ago would be appalled at what it means to be a patient, or an RN, on a MS unit in 2015.

I am sure it would be awesome for ONC. Long term patients, everyone already has met them, learned their baseline, learned their routine. Hell, some of the patients I see on the floor I may have had a week ago and I remember their story and their family.

[RyanCarolinaBoy, ADN, BSN, MSN]

No no and no. I worked at a va system that implemented team nursing and it was a nightmare. No one wanted accountability for anything. Each nurse had to find the other to ask questions all shift long. Simply give me my load of pts and I will take care of them. I find that in team nursing there is a lack of accountability. Plus, add in the days of getting thrown with the lazy nurse who's personality you simply can't stand. No thank you. I have done both, and much prefer primary nursing myself.

[RNBillieBSN]

In a "perfect world", TEAM Nursing could work. But we all know this is not a perfect world.

Having oriented for nine of the l-o-n-g-e-s-t weeks of my nursing career and life in an ICU Unit, I would have truly enjoyed the TEAM Nursing approach. But you have to be careful who and how you are partnered. If you are partnered with someone who is of the same energy and stamina, and knowledge level as yourself...then that's great...fine...it would probably be great!

You DO NOT WANT to be partnered with someone who takes a lot of cigarette breaks, leans or sits while you provide care or you end up "teaching" the entire shift, because your partners knowledge base is not up to yours. You will end up working yourself to a nub and the patient will pay the ultimate price.

(P.S. The reason my ICU experience was the longest in my life and my career, was because of my preceptor. I was older than she and had many more years of nursing experience. She said, "I feel like you have more nursing experience than I do, so if you need anything, I'll be at the desk."

That was my orientation. She sat at the desk and read. I was given the hardest patients on the unit.

One evening I had three patients on the vent, two others who were post-op and they brought me another from the floor who was crashing and as soon as he got there he went into V-tach and was unresponsive. No one had come in to help me get him situated. The floor nurses were gone. My preceptator was sitting at the desk reading. I finally went out and announced, "if someone doesn't come in here and help me, this man is going to die!" That got me some help. I ran my legs off all night long. My patients got high quality care. I had a compliment from a physician come morning because his patient's Swan's readings were readily available for him when he came in. As soon as I got off at 8:30 am I went to the Nurse Manager's office and that was my last shift in ICU. My preceptor, as I understood it, was given the option to transfer to the floor or be let go. Period. She put my patients in jeopardy. But I didn't care if it killed me...I was not going to let ANYTHING happen to them while under my charge. I would never do that to a patient or a co-worker.)