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

Imagine arriving on your Medical-Surgical unit one morning to find that you can share the burden of work with another nurse? Busy in an isolation room and can’t answer the phone? No problem! It will go to the other nurse’s phone. Busy passing meds and don’t want to disturb your concentration by helping the patient next door to the bathroom, but the tech is caught up doing vitals? Call your fellow nurse.

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

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 3rd 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.

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Lev

About Lev, MSN, RN, NP

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I dont agree, you can't establish a good patient-nurse relationship while team nursing. That is one of the most crucial parts of nursing in my opinion

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I believe that team nursing has it's merits. Most importantly, I think it's great to have a system of primary and secondary nurses in which each nurse is briefed on all patients within the team (i.e. I'm primary and you're secondary for my six patients, you're primary and I'm secondary for your six patients).

It's awesome when coworkers offer to cover your patients if you're busy or at lunch. However, I've seen many instances where there's little, if any, hand-off. More often, the transaction goes, "Will you cover for me?" "Sure." [Hands covering RN the phone and leaves.] That seems unsafe to me, especially when patients are high acuity.

The challenge is not to spread the team too thin, which would prevent nurses and CNAs from getting to know their patients, both psychosocially and physiologically. I've read that old-school team nursing functioned like an assembly line; one nurse did all meds, one nurse did all baths, one nurse did all vitals, etc. If team nursing becomes too 'shared' and fragmented, there's no way that a single nurse can get a full picture and assessment of the patient's condition.

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Specializes in Heme Onc.

We informally team nurse in a lot of situations. Mostly... admissions. One nurse does all the assessment/phone/call/charting while the other handles tasks/labs/monitors/supplies/iv starts etc. Or... once we've finished the initial assessment/medpass, sometimes we'll partner up with someone and give all the rest of the meds while the other hangs replacements and blood products. Just makes it easier to manage conflicting priorities.

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Specializes in Critical Care.

Team Nursing isn't necessarily a bad set-up in a low-acuity environment, it's still often used in Nursing homes for instance. And long ago when hospitalized patients were comparable to today's nursing home residents it was workable, but it's really not a wise idea given the acuity of today's hospitalized patients. You just can't compartmentalize care and more importantly patient management in today's hospitalized patient without presenting significant risks.

That doesn't mean the a more appropriate form of team nursing doesn't exist today in hospitals, in a properly function unit nurses help other nurses as available, which actually works far better if you haven't pre-designated which nurse it help which nurse, you just can't plan the flow of patient needs like that and trying to do so actually severely limits the ability of a floor to adjust as necessary, such as when a patient suddenly requires more close assessment and interventions.

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Specializes in Hospice.

We tried this on our step down unit and it didn't work at all. The doctors were asking questions and were getting upset because the nurse would have to ask the other nurse if Mr. So and so had received his metoprolol, or if Mrs. What's her face had less than 200ml out in her chest tube.

i agree though in certain areas of nursing this would be beneficial, but not in high acuity areas.

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Specializes in Neonatal Nurse Practitioner.

We have a primary/secondary nurse setup. When primary goes to lunch or runs to the bathroom, secondary is there. If primary doesn't answer the call bell/alarms, secondary's phone will ring. The tech is assigned to the nurses' station (there are 5 of those on the unit). Has some of the benefits of team nursing, but keeps the primary nurse-patient relationship intact.

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I think in some ways team nursing has its merits. I also would like to see us use everyone to the top of their license. Many organizations profess that nurses should be working to the top of their license, but make also sorts of rules to prevent it from materializing. It is usually because "a physician doesn't like that, etc." Nurse need to own their practice. There is a place on the team for NA's LPN's, RN's, and APRN's. What a dream it would it be to give individuals mobility to move to more advanced roles in the team as they gained experience and furthered their education! If team nursing gets patients what they need, then we may have to revisit. Increasingly physicians are now employees and may need to relinquish their prima donna status. Doctors need to look in the charts and stop asking to be spoon fed information. God forbid they round with the charge nurse and a WOW and look up the info or wait a few seconds for it to appear on the screen!

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I think primary care and team nursing both work with the proper amount of staff. If you start doing team nursing but continue to not have ancillary staff it won't matter because it won't work. It also depends on the nurses working within the team. And yes doctors need to start finding their own information instead of it being spoon fed to them.

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Specializes in Hematology/Oncology.
Mursinmaz said:
I don't agree, you can't establish a good patient-nurse relationship while team nursing. That is one of the most crucial parts of nursing in my opinion

I can see that you are a student. IF you ever worked in a Team nursing environment you would see the effectiveness of it. You do not always have time to do it. You can establish and listen to a patient in high need of distress while the other nurse has free time to assist you.

You can actually tend to psycho-social needs and education while your other nurse takes care of "some of the busy work".

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The issue with team nursing, is that the focus ends up being on the work to be done (task orientated), rather than the patient, and we all know the need of each patients can be quite complex, more than the simple act of attending to a task. I feel you can still work as a team but that each nurse has overall responsibility for a smaller group of patient's.

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Specializes in ED, Cardiac-step down, tele, med surg.

We have a relief nurse most of the time on the unit I work on which is helpful, who can pass meds, do blood sugars, plus cover us on our breaks. I wouldn't like a bigger load of patients, even if it was split between another nurse. I don't want to be responsible for more than 5 people. Honestly, I think that is the maximum number of patients that is safe for a med/surg/tele floor nurse. You never know what can go wrong. And there should always be CNA coverage and a relief nurse and a charge nurse. I think anything less than this is understaffed and this can be a safety hazard and lead to high turnover because it is stressful to work short staffed.

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