RN total patient care... - page 5

by julz68

I'm just curious how many of you work in hospitals that has gotten rid of all LPNs and CNAs. My hospital is moving in this direction and a few floors have went to RN total patient care. I don't mind doing everything myself, but I... Read More


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    The concept of RN total patient care is based on each nurse having few enough patients to make teamwork by all of the RNs to make very high-quality patient care possible. With the levels of acuity of the usual med-surg patient, I'd guess that the max assignment would be 3 to 4 patients. Unfortunately, from what I've heard, US hospitals that start with those kinds of patient assignments soon start the gradual process of increasing the average assignments without changing staffing patterns, increasing the numbers of patients without reintroducing the LPNs and the CNAs.

    When the associate degree programs were begun in the US, the programs were based on an advanced degree thesis or dissertation written by, I think, Mildred Montag. She proposed meeting the then current nursing shortage by introducing a new category of nurses, the technical nurse, with a 2 year educational program. This technical nurse would provide care for the "average" patients on general nursing units while the diploma nurses, and even more so, the BSN nurses would provide care for the complex, unstable, patients. This immediately, as far as I can tell, morphed into just another way to become an RN. Unfortunately, it is NOT possible to cram into 2 academic years all of the science, general education, and clinical courses that are necessary to EDUCATE a well prepared registered nurse. After over 40 years of combined experience in hospital nursing and nursing education, I've come to believe that it takes a minimum of 3 years of concentrated education to prepare a good registered nurse. Now, almost all graduates of good associate degree programs take 3 years to complete all of the science, general education, and clinical nursing courses. Unfortunately, they still lack some of the breadth of education that a good BSN program requires. The average BSN program in the US requires 2 years of concentrated general education that is intended to provide a basis in science and "patterns of thinking" in the liberal arts and mathematics, then 2 years of focused clinical instruction that adds more instruction and practice in critical thinking and the use of all of they have learned to the care of people with health problems as well as health promotion activities to reduce risks of future illness or injury.

    It is common for many people who have limited training in health care to focus on the tasks of health care -- the giving of medications, taking vital signs, providing hygiene assistance, etc. -- to decide to pursue education to become a registered nurse because "I already do all of the work so I want to get all of the pay." It is a difficult situation when that happens -- I've had a number of such students and they can be difficult to teach. Some of them never see the difference between doing the tasks (and reporting to the nurse who decides what to do with the information), and gathering all kinds of information, carefully focus their analysis of that information, and provide the critical thinking to provide plans A, B, C, D, etc. to provide the best quality care to an individual in a specific situation to assist in preventing future health problems, restoring health to the extent possible, or assist with a peaceful death. Some of these folks graduate with an ADN or a BSN and go out to provide care and drive their peers and supervisors crazy because they can't go beyond doing the tasks. These are the nurses who drive their charge nurses crazy when they can't go past a Plan A in problem solving. Ah well.

    Finally, in my experience, staffing patterns go through cycles in this country. In my mind, there are a limited number of ways to organize patient care in acute care settings. You have the total patient care by RNs pattern that was common when true nurses training in the US was initiated; then you have "team nursing" where a small group of personnel with varied educational and training preparations provides care for a group of patients, with each person on the team providing care based on her/his abilities; you also have "functional nursing" where each person on the staff provides a given sort of care (the RN gives all of the meds, the LPN does all of the dressing changes and treatments, CNA 1 does all of the hygiene and toileting for patients 1-8, and CNA 2 does all of the hygiene and toileting for patients 9-16, or whatever). These have undergone a number of name changes over the years, and people with argue vehemently that modular nursing is very different from team nursing and the primary nursing (where one nurse bears primary responsibility for planning and organizing care for one patient for the patient's entire hospital stay) is very different from team nursing or total patient care, but I think the basic organizational patterns are unchanged.

    Finally, in the US, my observations indicate that:
    1. Hospital "bean-counters" never study the history of effects of nursing staffing patterns
    2. Hospital "bean-counters" never pay attention to the differences in the averages of the kinds of care provided by nursing personnel of various levels of training, education, and experience
    3. Hospitals, therefore, go through cycles of deciding that it makes better sense to hire 2 nursing assistants than one RN; that it's better to find a way to get rid of an RN with 30 years of experience and replace that expensive RN with a less expensive new graduate RN; and that it makes way more sense to have as few RNs on any shift on any unit as possible, because they're the most expensive nursing personnel working at any hospital. This lasts until patient satisfaction scores plummet and/or the number of VERY expensive malpractice suits skyrocket, and then the trend reverses to hiring as many RNs as possible. A decade or so later, the entire process will recur.

    I await the comments of others. :-)
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    im a Canadian rn on a busy telemetry floor, rn's and rpn's each have their own assignments, which consists of 5 patients, or sometimes 4 on a day shift, there are 2 psw's and they are assigned 10 pt's. we have 43 beds. psw's are done at 1500 and everyone picks up 1 pt. we do our own total care as psw's don't usually time for most of the patients. the hospital is also laying the psw's off. at 1530 the charge nurse is assigned 3 patients, at 1800 we have no clerk, the clerks will not answer any call bells. at 2330 u r assigned 7-8 pt's and you are on your own, it is hard to get help on the evening shift as everyone is so busy with their own pt's. we do work as a team if it is very busy and try to help other nurses. Canadian patients are very demanding and so are their families. a male patient had barked at an rn and told her she took far too long to serve him. she replied, this is not the military and you are not my commanding officer. we have the same issues as usa, drug seekers, alcoholics, fake symptoms, people who make formal complaints and threaten to sue us. one time we were transferring an elderly patient from another unit as she was to receive tpn, her daughter came to the desk and said to me, is the tpn here yet. I said, no it is not. she said, if it is not here in 30mins I am phoning my lawyer. she came back in 30mins and said is it here, I said, no. she said, I phoning my lawyer. I said, ok. this was a sunday. pharmacy arrived with the tpn in 15 min.
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    I am an RN in philadelpihia and the hospital at which I work is also moving to the all RN model. My floor (cardiac step down unit) was the first to roll out this model. RN's max out at 4 patients with a charge nurse to support during busy times. Patient satisfaction did go up with this switch. It is a very busy unit with a lot of completes and it is completely doable as long as you have a supportive team that you work with to help you at busy times. I feel doing everything for the patient goes me better control of what's going on (better skin assessments, knowing your vitals rlght away and changes from baseline).
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    I see this as a safety issue, safety for both nursing staff and patients. I have worked as an RN for 30 years in all types of staffing arrangements. The ones that worked the best included CNAs, unit clerks and licensed staff. When I started my nursing career, we worked as a team, one RN, one LPN and one or two CNAs and 17 patients. We all worked with all of the patients. This was a great way to teach also, my CNAs and LPNs worked with me and learned or at least observed how to do everything I was doing. There were many things they could both do that did not require an RN license.
    For example, one night we had a new colectomy patient who needed frequent colostomy bag changes. I had some tricks up my sleeve that I taught my CNA when we first came on shift. Later in the shift, when I was stuck in a room starting an IV, my CNA was able to prevent a complete blowout of that bag with what I had taught her earlier. She never would have touched the bag before but felt confident enough to apply what she had learned. This was not a skilled or license only activity but something that saved my patient a lot of discomfort and embarrassment.

    Then, in the late 80's, admin got the great idea to move to primary care nursing, it was all the rage back then. I believe it was simply because they thought they could save money. Primary care works well if everyone has backup to help when they need two people or when they are working with another patient. With a well staffed unit, we were able to take up to 10 patients, mom/baby pairs at night and feel like we did a great job. Admittedly, 10 patients on a med/surg unit would be too many. Lifting/turning a patient without two people is dangerous, for both staff and patients. A unit clerk can answer call lights and help patients feel they are not being ignored. That same clerk can prioritize or triage those calls and communicate urgent needs to staff that may be stuck in a room.

    When support staff, CNAs, clerks, are removed from the patient care picture, patient satisfaction rates drop and staff retention drops. My last unit had me staffing the night shift alone with up to 5 patients PP, PostOp, each night. When I say alone, I mean ALONE. I was housekeeping, dietary, lab and nursing all in one. If I had a patient that needed labs drawn, I had to draw them myself and run the blood to the lab, on the other side of the hospital. I was cautioned that if I left the laundry basket in the hallway with dirty laundry in it once more, they would sanction me. The laundry chute was also far away from my unit. Dirty food trays had to be walked to the next unit over to deposit them. Garbage cans were always overflowing, they were small and would fill up with one chux, and had to be dumped outside in the dumpster. This was a 400+ bed, inner city hospital! The L/D nurses were supposed to come over and help if I ran into problems but I had no way to call them quickly and they were really deaf to my call lights. There were many a night that I would go over to ask for help, while running crazy, to find them watching TV in the lounge. Even after asking they would refuse. I typically never left until at least 2 hours after my shift ended because I needed to catch up on charting. This unit is dying, losing its patients to other, more satisfying hospitals. It is poorly laid out, making staff walk much farther than needed to access linens, supplies and patient rooms. Instead of revamping it for improved function Admin and owners decided it needed a new style so they put over a million dollars into paint, flooring and new art work. They also decided to offer salon services, a hairstyle or pedi, to their patients while they were in-patient so they took out the family lounge and put in a salon. At the same time, money was so tight that they couldn't shut down the halls that were being remodeled, we had to work around the painters, ladders and floor installers. Needless to say, we nurses were just shaking our heads and rolling our eyes.

    This unit had a lot of personnel issues and I quit after only a few months. It was a toxic place to work. It was also the most unsafe of any facility I have worked in and where I felt the most at risk for being sued by a patient.
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    I'm a PCA and I think getting rid of aides would be stupid. Not only do I do vital signs and I and o, I also clean patients, change linens, collect specimen and draw blood (I also straight cath and insert foleys at my other job), help patients to the bathroom, get accuchecks, turn and clean incontienent patients and...the list goes on.

    As for LPNs, my hospital doesn't hire them anymore but we have a couple who were grandfathered into the system.

    If RNs are expected to do total patient care, then the ratios need to go down to three or four patients per RN.
    mds1 likes this.
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    Quote from weemsp

    I'm wondering where in Canada this is the norm??? I've worked in hospital settings for more than 21 years...in ALL that time I've NEVER seen any unit without LPNs and CNAs.
    Canada here. We have LPNs but they do total care on their own patients, and the RNs do total care on their patients. We don't have CNAs as part of our regular staffing.
    Fiona59 likes this.
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    We are dealing with this issue right now. Working on the mother baby floor with no CNA, having up to 5 mom or GYN pt. Nursery nurse responsible for babies. Many times no US to answer the door on our locked unit. We carry phone for our pt to call. I mentioned in another post, actually asking and receiving input re; staffing since we are moving back again to couplet care and becoming baby friendly. I presented info at our Best Practice comm. mtg, that 3 couplets max to make this work without a CNA. I remember doing team nursing in the 70's, it worked on that floor at the time.
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    Total patient care? Ain't nobody got time for that!

    I work in the ER, and I generally have 3-4 patients under my care. We also have two techs, but each of those techs have to help with 13 beds. If I have more than one seriously acute patient, I get swamped quickly. I don't mind doing everything for my patients, but sometimes I have so MUCH to do that I just can't manage it all in a timely manner. I really feel for med-surg nurses. I always feel guilty when I have to admit a patient


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