Absence of Teamwork

[Ruby Vee, BSN]

nursing has changed a lot in the past thirty years, but when i reflect upon it, it isn't so much the technology, although that is definitely a factor. it's more about the nontangible things -- ethics, the courtesy and gratitude of patients and their families, and the teamwork of the staff. if i had to put one of those above the rest, it would be the lack of courtesy and gratitude. but a close second would be the absence of teamwork.

team nursing was still the unit structure when i started nursing. primary nursing had just come into vogue, but it hadn't yet filtered down to the small midwestern community hospital where i was working. we worked in teams. thirty beds, fifteen to a hall. two teams led by an rn and staffed by a combination of one or two of the following: a less senior, less experienced rn, a lpn and /or an aide -- because that's what we called them then. the assignment was a shared one: the two of us or the three of us were responsible for our 15 patients. the team leader passed scheduled meds, called the doctors, took off the orders, etc. the lpn or junior rn did prn meds and treatements. and the team member or members were responsible for adls and toileting. we all worked together.

i remember working with an na and cranking out 15 baths and linen changes together in a morning. we'd go into a room together and work together until that room was finished and move on to the next one. if someone's patient was incontinent anyone who was free changed him and everyone who was free helped. the closest person answered a call light. there was camaraderie. we worked together. there was none of this sitting at the nurse's station while everyone else was busy running around. either we were all working or we were all sitting.

these days, or maybe it's just this unit, we don't work together. we can all work in one big room, six patients. one nurse is running her posterior off while a second sits on hers and looks at facebook and the third does chart audits and bugs the first nurse about missing admission documentation rather than offering to help with the hourly glucose checks, taking a line out or pushing a wheelchair down to the step-down unit. the 20-somethings are all friends, which is great. they'll help their friends out if needed, but they won't help anyone else unless asked directly and even then sometimes they won't. i remember trying to make a patient comfortable a few weeks ago -- you may remember that vent -- and the 20-something guy i asked to help me came into the room, helped me boost my patient and then went back to his facebook page while i was still asking the patient if he was comfortable yet or if he wanted to be turned some more. the charge nurses will sit at the desk and read your computer charting in between bids on ebay and call you to come out to the desk and explain why you haven't gotten the hourly glucose for 80 minutes rather than getting up and coming to help you out or at least to investigate. did you fall asleep in your room? are you wrestling with a sundowner? did you have a syncopal episode? did your computer crash the minute you finished your charting but before you signed it? or are you too freaking busy to get to the glucose and thus possibly too busy to come out to the desk and explain why you didn't?

years ago, i was involved in a sentinel event. among many other factors was the fact that instead of helping me with an overwhelming assignment that included one patient crashing while an inept resident attempted to do a procedure on her while the other (stable) patient screamed continually for ice and her family kept pushing the curtains back to threaten me with legal action or bodily harm because i was "ignoring sister because she's black," the charge nurse was sitting at the desk reading my computer charting and commenting to all of the other nurses on shift who were sitting at the nurse's station about what i was doing wrong. how would she know? she never even popped her head into the room to look? nor did anyone else who was listening avidly to lab values that charge was reading out: glucose of 22, hemoglobin of 5.9.

i'm not saying all nurses are like that, or even all of the nurses where i work. but it's an alarming majority.

i miss the gratitude and courtesy of patients and their families. but i sure miss the teamwork, too.

[caliotter3]

It is a wonder I ever continued in health care. At my very first CNA job in a LTC facility, all the CNAs except me and one other, didn't come to work one day. Talk about busy. The other CNA was at the nurses station for the day. She did absolutely no patient care. Left all of it to me, then yelled at me because I wasn't finished at the end of the shift. I never figured out how she could spend the day sitting on her rump at the nurses station when there was plenty of work to be done and obviously I couldn't do it by myself. In the ensuing years, I have found that situation to be a better description than one of actual teamwork. Teamwork in the workplace is rare when it comes to nursing.

[General E. Speaking, RN, RN]

I remember team nursing and miss it too sometimes. I was a LVN back then but when paired with the "right" RN, we could bang out a whole bunch work seamlessly. Typically, if I recall (this was about 18 yrs ago ) we were assigned to 10-12 patients. We hit the ground running after report and began bagging up our linens, dropped them in the rooms, checked the blood sugars and covered w/ insulin. We would do vitals together and form a game plan. I would start the meds and she would begin assessments/baths. When I finished a.m. meds, we would team up and finish the baths or if I was overwhelmed, she would help me w/ meds/dressing changes.

Since moving to ICU, I have had maybe two days where I barely have time to pee while others where surfing the net. I know if I would have asked, they would have helped me. I knew I would eventually get everything done so maybe my pride stopped me from asking. I managed to get my work done but left feeling exhausted. I try to offer help (without their asking) when I see that my fellow nurses are getting bogged down with a patient that turns busy.

In general, though, I feel like we have a "team spirit". Just depends on exactly which nurses are working. Unfortunately, some are just lazier (or more unaware) than others

[iNurseUK, RN]

It isn't like that everywhere Ruby Vee. My current ward does have three official teams but we all offer help if we are in a quieter team as opposed to the busiest one.

It's an old hospital with what is, I guess, an old-fashioned way of working and very much none the worse for that.

I and any other nurse on the ward will attend to a call bell or an alarming pump regardless of which team it is in. Any patient who calls out to me in passing I will attend to and so do most of us.

[livinthedreamRN]

Just the other day (a very bad, frustrating day,) I asked some of our senior nurses who have been working this same floor for over 30 years how they made it this long. Their answer was that it used to be fun....FUN???? They said it is so different now. I didn't have the time then to ask what was so different but I will. I'm sure it's because of the same things the op mentioned like camaraderie and teamwork.

[Lacie, BSN, RN]

When I started out my first hospital was Primary Care and had been at each and every one after that. Then I left hospital to work in Dialysis which of course was supposedly "Team Work". Now in Home Health I see more Team work then I ever did anywhere else I have encountered as far as the field nurses go but when it comes to the office that's an entire new story lol. Office politics of who got to go to lunch first or "why is your work always done and I have a pile" (hmm because I dont spend half of my day making cups of tea and walking around gossiping my 8 hours, also offer to help the other CLM who may be behind, yet you have never offered even one time to do so, I'm not 15-30 min late coming in every single day as I am at my desk starting my actual work day soon as hit that desk).

Things have changed a lot in work ethics also! People didnt call in every other Monday after a weekend off or the Friday before. And when the big boss isnt there I dont take an 1 1/2 hr lunch break and then leave 1 hour early). We dont clock in or out or write times for the CLM's. We do for lunch but it's funny to see they left at 12, returned at 1 yet in reality left at 1145 and returned at 1:30 lol. Just astounds me sometimes. It's different every where, sometimes you end up with a great group of co-workers who can pull it together as a real team and other places you dont. I learned over the years to "pick my battles" and what to let just roll off my back also. Since doing so lot of less stress and a heck lot happier.

[DogWmn]

I agree Ruby Vee, I'm from old school and we had real team work going on. This was pre computers, cells and other electronics. I worked in an all nurse hospital only RN's and LPN's we had unit clerks on 1st and 2nd shift, we also had plenty of staff back then, I did my year on med-surg and was asked to transfer to Ortho and did, it was great team work. Our teams were broken down differently we had 1-2 RN's (mostly only 1) one who would be "charge" and if there was a 2nd (usually a newbie) she would take one team and pass meds the 2nd team charge was an LPN the was Med Certified (long before there was IV certs), then the patient care on the noob RN's team was done by the more experienced LPN's and the LPN's team was made up of a mix of noob LPN's and experienced. The charge was always a very experenced nurse she'd handle doc's new orders make sure everyone got their break! dealt with any pt's going south she'd even answer a light or 2 on occasion. We all worked together, pt acuity was taken into consideration on who should get what pt. As an LPN it was great, once I got my advanced Pharm course I was part of the pool of LPN's that rotated the team leader position and if we had a large amt of high acuity patients we did the total pt care thing with just 1-2 pts. We were a team, we were flexible, we worked hard but never felt overwhelmed and there was ALWAYS someone to ask for help and they would give a WILLING hand. And this was back in the day when it was hand written charting with colored ink;). Our patients got excellent care. We never walked past a light on no matter who's pt it was. Our charge nurse was old army and a bit of a stern task master but I learned so much from her, pt's always came first no matter what, but she did an amazing job of running a tight ship, being creatively flexible with assignments so no one was overwhelmed. When we had admits on 2nd she would handle the paper work while *gasp* the admiting nurse (LPN) did the initial assesment...LOL if it was a newer LPN she'd come down and help and train but ultimately the LPN was the chart mistress. It was not unusual for an experienced LPN to be "training/orienting" a new RN or vice versa *gasp again*. We were there to work, not sit at the nurses station, not look at my cell or talk on it, not play on the computer. I will say that the patient loads were much more manageble than what it appears they are today. But still it was teamwork that got us through each shift.

[Flying ICU RN]

(or more unaware) than others

There is a term in aviation known as "situational awareness." Knowing your location in time and space and all that is occurring around you. I've used this to great effect in my nursing career and while mentoring others.

[DeepFriedRN]

You know Ruby, I only have 8 years under my belt, but when I first started, there was a lot more team work. I'm in CA, where there are ratios. As such, since nurses on tele have "only" 4 pts, admin assumes CNA's and LVN's are not as necessary. So 31 bed unit, 2 CNA's. (and per the union contract, they only have to take 6 patients each) When I started (before ratios), I had 6 patients, 4 of whom would have an aide (4 aides on the floor). With 2 sets of hands, things moved quickly and efficiently. Now, it's pretty much every man for himself. I miss the old days. We are creating nurses who don't feel the need to step up and offer help to anyone. The basic care that pts deserve is getting sidelined. Yes, we have to monitor tons of stuff, but it takes approximately 15 minutes to bathe a pt if there are 2 people. I hate to think that pts go 3-4 days without basic hygiene. How would each of us feel if we had to go that long? I miss teams. They made for better care, and better nurses.

[scoochy]

Ruby Vee,

I could not have said it better. Team Nursing was the epitome of team work!

[MassED, BSN, RN]

I hate the fact that I believe in teamwork and very few around me do. I won't change my personal work ethic. I'll help patients out, but it is not the nurse. I want to help those in need, not those who can't, or more likely, WON'T, prioritize or take the time to be concerned about others. I am new to the profession (only 8 years into nursing), but I have found that there are some out there who are my team mates, but most I have grown accustomed that they will not be there when I need them. I feel like a witch to have to ask someone the obvious, like, "HEY! We need a little help here!" Such insight is not needed. Makes me wonder how many of my coworkers (and in general) perform in critical situations, such as in your story of how that charge called out a glucose of 22. Just rattling off info with no processing. Makes me so frustrated. All I know is that I can take care of my patients and usually take it upon myself to eyeball those patients of those nurses that I feel might not attend to many needs. What else can you do. We should all approach it as OUR patients, not just mine or yours. I don't know where things have gone wrong. Before I was a nurse, though, I was helpful in my other jobs. I would never let someone flounder who needed help. It's crazy to imagine NURSES letting others kill themselves why they browse the internet. Oblivious to their coworkers. But that's all I have ever known in nursing. Not all of my coworkers, but the majority of them are pretty selfish in their nursing practice.

[MassED, BSN, RN]

There is a term in aviation known as "situational awareness." Knowing your location in time and space and all that is occurring around you. I've used this to great effect in my nursing career and while mentoring others.

many nurses, I believe, become so focused, a kind of tunnel vision on their task. Those are the ones we don't need in the ER. You need to be aware of all that's around you, all the sights/sounds and be prepared for what might come at you. You have to be able to help those that have sicker patients and hold your "priorities" until the sickest have been traversed out of the crisis. I don't know why this isn't the norm, really, I don't. Drives me to drink.