Has anyone tried team nursing? Opinions? - page 2

by circularstaircase 5,230 Views | 21 Comments

The hospital that I work with is going to be changing it's model from primary nursing (I would get 7-8 patients per shift) to team nursing (1 RN, 1 LPN, and 1CNA) for up to 12 patients. The LPN would be doing all the medications... Read More


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    OK so I''m old enough to have worked in a team nursing environment and I loved it, we only had LPN's and RN's no aids,techs etc. The new grad LPN's did the patient care until they could take their advanced pharm courses and sometimes some of the new grad RN's did the same, then there were rotations for med passing or we did total patient care including our own meds. But it was a very different world back then, everyone pulled their weight, we all left on time because if someone got buried with a late admission we all pitched in to get it done...including shift supervisors on occasion. Blew me away when I was working Ortho and we had several late admissions to our floor due to some traumas, the shift super came up and helped me set up a striker and get the patient transfered into to bed and set up. It was really TEAM work, we also were staffed well, we had floats that would be sent in for lunch breaks if necessary or help out if our census went up. These floats were very very experienced, sent to the "hot spots" throughout the shift we had both LPN and RN floats they were the cream of the crop, they also worked a regular schedule.

    Today health care is all about the money, not the patient and it shows.
    R.NICU likes this.
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    Team nursing is not a new model it has been around for years and practiced in California until the ratio law was passed. There are pros and cons to the system and I have done it all team..primary...charge nurse on both systems.

    It allows the RN to focus on the tasks and skill that only they can do such as the nursing process and plan of care and evaluation of that care. Administering IV therapies per licensure (varies by state) LVNs can do some of this, Calls to MD. role of team leader and setting a plan for the day and modifying the plan as needed. The RN needs to take charge of the team and needs to delegate well and know exactly what the LVN can legally do. Communication is imperative and team members must sometimes work to improve this. If you like to work somewhat independently this model can be challenging. It also can be difficult for some RNs not to see every wound and other things but it is important to get a report from the LVN in a timely manner so if there is something you need to see they come and get you. You need to communicate with your LVN what you want to be made aware of. For example ,if you a fresh post-op with a Thyroidectomy you want to be notified of any s/sx of hypocalcemia or if you may want to be notified if a patient is febrile.

    You need to be good at keeping track of a lot of things so you need a really good worksheets. I think you need to see every patient especially if you are working with an LVN you are not familiar with! The IV therapy can be overwheming on some days. I usually had a team from 12-14 and I hung a lot of IV antibiotics and antifungals and other IV medications ..up to 20-40 per shift. So have a good system with a stock of all the little things you need such as IPA scrubs and flushes. Try to group your tasks b/c you will be doing a lot of hand hygiene and your hands can get really dry not to mention it is very efficient. Before you call the MD...make sure there is nothing else you need for that pt..check with the LVN...this will eliminate mutiple calls to the MDs or LPs.

    If you are working several days in a row it really helps to try and keep the same general teams and try when possible to not split the the rooms too much although it is necessary to do it.

    Many RNs like this model b/c the LVNs and aides end up doing most of the baths,bed changing,toileting and tasks of that nature. Sometimes because of this and the fact the model places the RN in a supervisor role the LVN and aides will develop some animosity towards the RNs. If this is not controlled it can create chaos and anger on the unit. To stop this each member must know and feel they are a valuable member of the team. Always address them with respect..remind them they are valued..thank them for a job well done (when it is so)...offer to help and pick up the slack...(very important)..comminicate your expectations clearly..provide support as needed..make sure your team members get breaks. All of these work wonders and your team will work their butts off if they feel appreciated!!!! The RN has to be the leader and the backbone of the system.
    Last edit by iluvivt on Dec 26, '12
    R.NICU and NRSKarenRN like this.
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    I think it depends on several factors. Unit size is important. We get an LPN that passes meds for the entire floor (with RNs doing all IV meds and usually a couple patients regular stuff to help out). I wouldn't like to take 12 and have an LPN and a CNA. I know some places where LPNs take patients and have RNs do pushes and blood and central line management if needed on their patients. I love having an LPN when I have my 8 patients. She mainly does accuchecks and passes PO meds while the aid does the aid work and I do my assessments and communication with the docs or whatever is needed. It usually works well.
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    The unit I worked on for years tried it for awhile. I hated it. No one could really get the gist of it. The docs hated having to deal with more than one nurse ( usually). I'm sort of a control freak when comes to caring for my patients...I like to be on top of everything and that's harder to do with team nursing, IMO.
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    I work a medical with tele floor on nightshift with the team format. On nights, we can have up to 12 patients with 1 RN, 1 LPN, and 1 aide. On days and afternoons they can have up to 8 but usually only 6 or 7 patients with a team. There are some good points and bad points. If it is a busy night or you have some more intensive patients, it is hard to get a good feel for what's going on with your patients--there are just too many for that. Usually we start out the night with the LPN looking up the medications for the night whil I check charts for new orders or important labs. At midnight, the LPN starts getting vitals and doing med passes. I will usually go with her to do my own assessments (saves on waking the patient ore than necessary, and we can take care of turns at the same time). Usually by 0200 I have seen everyone. I spend the next six hours charting my assessments, calling for any issues (love having hospitalists), and putting out any fires. Some nights I am incredibly busy with demanding patients, pain medications (LPNs can't do IV pushes at our facility), someone taking a turn for the worse, ect. Other nights, I am on top of everything, ect. Something I do enjoy about the team format is having other hands available for help and another set of eyes on our patients (especially as most of the LPNs have 3+ years experience and I have about 7 months). My night can be made or broke by what my team is like--if I have to follow the LPN or aide to make sure they do their actual job duties or don't cut corners or if the LPN doesn't tell me about critical changes with vitals, that makes my job harder than it should be. On the flip side, if the RN has no clue what she's doing, refuses to listen to the LPN when there's a change (ie, refuses to call the doctor), then the LPN has a rough night.
    I used to hate the team format (I do work primary as well on our oncology unit), but the teams on our unit are great--everyone pulls their weight and more.
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    I did it at the VA. I hated it. We had one RN who was the charge nurse, they did the admits, discharges, assessments, and dressing changes for 20 patients. If it was the day or evening shift there was a LPN to pass medications. Also if it was the day or evening shift there would be 1 CNA and the rest of the RN's would work as CNA's on the floor.
    On NOC shift there was one RN and one CNA for 20 patients. For me it was unsafe, and a waste of talent and money for the RN's who were working the floor. They were not allowed to help with the "charge nurse" role.
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    I worked in a free standing psych hospital where we did team nursing of sorts. There were six units with 13-26 pts in each unit. We would get one RN who was "charge nurse" and an LPN who was "med nurse". Charge would do admission, discharges, and dealing with the treatment team. Med nurse passed all scheduled and prn meds along with helping with note. Then 3 MHWs who did checks and vitals. This worked well enough.
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    We follow team nursing on the unit on which I work. It is often confused with "functional nursing" where each member of the team has a very defined and narrow role (ie vitals or meds). That is not what team nursing is.

    The main feature is the "team conference" where all members of the care team have input into the plan of care. The emphasis is on communication and working together to provide comprehensive care--thus everyone has a responsibility to get the work done for their team as their scope allows.

    The role of the charge nurse is usually bigger in team nursing, and on our unit it is the charge nurse who primarily deals with paper work and doctors, relaying that info to the team nurses as needed (who are able to focus more on direct care). It is a particularly good model for inexperienced nurses because there is more supervision of their practice, and the charge is more aware of what is going on with the patients.

    The main advantage over primary nursing is that one nurse isn't expected to shoulder the responsibility for everything, with increasing duties and responsibilities falling on the primary nurse. The workload is ideally distributed a little more evenly.

    Additionally it is democratic. For anyone who prefers an egalitarian environment where decisions can be discussed and decided on as a team, team nursing might be a welcome change (conversely, people who like to be in control usually hate it). Since decisions are made as a group, there's a higher chance of someone catching mistakes or coming up with a new and workable approach. People can also play to their strengths and contribute different types of expertise, and it's easier to learn from other team members and disciplines in ways that the primary model doesn't allow.

    Most problems with team nursing have to do with a team that doesn't "gel" and work together. As we all know, being forced to work with the same patients doesn't make people a "team"--just as in athletics, the team that doesn't work together doesn't succeed. For example if you work with lazy people, you still have to get all the work done yourself. If there is a high turnover rate on a particular unit, the team members don't get to know each other and usually don't communicate well enough. The care can be really fractured without good communication and co-operation, with team members disagreeing on an appropriate approach or missing things when they don't communicate.

    In my experience, you really need a strong base staff for team nursing to work. If you don't have that it can go pear-shaped pretty fast.
    elkpark likes this.
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    I should also add that our teams consist of 1 RN, 1 LPN and 8 patients (or ten if there are overcapacity patients). LPNs in SK have a much greater scope of practice than basically anywhere and thus often function simply as a second nurse, with only a few tasks left solely to the RN.
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    We currently do this, 12 patients with an LPN and aide. I don't like it just because I prefer to do my own vitals and dressing changes and med passes, although I have to say it all depends on what your team is like. It will be a good night with a good team, bad night with a bad team.


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