What DON'T you like about primary nursing?

MollyMo · Oct 30, 2002

I did team nursing in the beginning on my first job. Later we switched to primary. I preferred team nursing because we had a good crew who worked well together. Primary nursing will help sharpen your assessment skills since you have only yourself to rely on. Timing and prioritizing will improve for the same reason. Primary nursing works well if you have a reasonable patient/nurse ratio. And if you have a good resource person. That's about the only negative I can think of now.

MollyMo · Oct 30, 2002

I did team nursing in the beginning on my first job. Later we switched to primary. I preferred team nursing because we had a good crew who worked well together. Primary nursing will help sharpen your assessment skills since you have only yourself to rely on. Timing and prioritizing will improve for the same reason. Primary nursing works well if you have a reasonable patient/nurse ratio. And if you have a good resource person. That's about the only negative I can think of now.

beckymcrn · Oct 30, 2002

I worked on an oncology unit where we did primary nursing.

It has its ups and downs.

As a primary nurse you have only you to get the job done. SO on day shift you would start the day with beds and baths, hopefully if nothing else was going on. Move on to pass meds, hopefully you would get done before the docs came in. Basically you would run through the day trying to get things done BY YOUR SELF. with very little help because every other nurse on the floor was a boged down as you were. :chair: . So by the end of the day (12 hr shifts) you were exhausted and maybe just maybe you were lucky enough to finnish your tasks before the night crew came in.

The only plus side I saw to the whole thing was that I was doing the work so I could make sure something was done and not have to hope someone else was doing their job and it would not come back on me.In other words I was only responsible for my own work.

beckymcrn · Oct 30, 2002

I worked on an oncology unit where we did primary nursing.

It has its ups and downs.

As a primary nurse you have only you to get the job done. SO on day shift you would start the day with beds and baths, hopefully if nothing else was going on. Move on to pass meds, hopefully you would get done before the docs came in. Basically you would run through the day trying to get things done BY YOUR SELF. with very little help because every other nurse on the floor was a boged down as you were. :chair: . So by the end of the day (12 hr shifts) you were exhausted and maybe just maybe you were lucky enough to finnish your tasks before the night crew came in.

The only plus side I saw to the whole thing was that I was doing the work so I could make sure something was done and not have to hope someone else was doing their job and it would not come back on me.In other words I was only responsible for my own work.

renerian, BSN, RN · Oct 30, 2002

We did primary care on the onc/bmt unit I worked on. I spent way to much time doing non nursing things. We had an all RN floor no aides, no LPNs, No runners and sometimes no charge nurse. I spent alot of time off the floor running errands. Had to stop in the middle of a bath all the time to get call lights, pain meds and such. Need decent ratios to do it or you won't like it......

renerian

renerian, BSN, RN · Oct 30, 2002

We did primary care on the onc/bmt unit I worked on. I spent way to much time doing non nursing things. We had an all RN floor no aides, no LPNs, No runners and sometimes no charge nurse. I spent alot of time off the floor running errands. Had to stop in the middle of a bath all the time to get call lights, pain meds and such. Need decent ratios to do it or you won't like it......

renerian

Allison S. · Oct 30, 2002

We practice primary nursing in a slightly different way than what I am seeing described here. I work in a rehab hospital where average length of stay is 3-4 weeks, and some patients are with us for months.

In our version of primary nursing, each patient has a primary nurse who takes that patient everyday that she is in. The patient will also have a primary OT, PT, and SLP as appropriate. We refer to each patient's group of primary staff as their team. We also have nursing aids and rehab aids, and their assignment is pretty consistent too, as staffing allows. (Not all patients have an aid assigned, some not every day, some not at all.)

So the benefit here is consistency. The downsides are that it can sometimes get taxing to have the same difficult patient every day you work, and also, there must be other nurses to fill in when you aren't there. These people aren't on the team and have different patients everyday are not always up to speed on the patient's care plan. Also, it can be hard to balance teams: depending on acuity and census, etc. one team can end up much more acute than another for a time. Sometimes we swap, but we try not to so that we can maintain consistency.

I am eager to talk with anyone who does primary nursing this way.

Allison S. · Oct 30, 2002

We practice primary nursing in a slightly different way than what I am seeing described here. I work in a rehab hospital where average length of stay is 3-4 weeks, and some patients are with us for months.

In our version of primary nursing, each patient has a primary nurse who takes that patient everyday that she is in. The patient will also have a primary OT, PT, and SLP as appropriate. We refer to each patient's group of primary staff as their team. We also have nursing aids and rehab aids, and their assignment is pretty consistent too, as staffing allows. (Not all patients have an aid assigned, some not every day, some not at all.)

So the benefit here is consistency. The downsides are that it can sometimes get taxing to have the same difficult patient every day you work, and also, there must be other nurses to fill in when you aren't there. These people aren't on the team and have different patients everyday are not always up to speed on the patient's care plan. Also, it can be hard to balance teams: depending on acuity and census, etc. one team can end up much more acute than another for a time. Sometimes we swap, but we try not to so that we can maintain consistency.

I am eager to talk with anyone who does primary nursing this way.

ceecel.dee, MSN, RN · Oct 30, 2002

I don't think the ratio's will be the problem.

I'm more worried about how the RN's will view their role change. We employ RN's (quite short of these), LPNs (thank god for plenty of these) and CNA's. The LPN's and aids do pretty much all of the patient care and the RN's (typically 2/shift) run around trying to cover everything it takes an RN to do: one is assigned to charge (we all rotate this role) and the other covers ER, OB, ICU when it's open, IV starts, IV push meds, assessments where needed, admits....you get the picture.

My concern is, if the second (and sometimes third) RN is assigned patients, who will have time for all the extras? It seems to me that we will still need this "floater" who is free to cover for the unexpected. This will actually take more nursing hours and budget have to be considered. And, when all RN's are used to charging, how will they adapt to reporting patient info to THE charge, as one still needs to oversee all and have the big picture. The DON does not want to "promote" a few to this designated position as "we have so few that they all need to be able to fill this position, stay familiar with all tasks, etc."

Is a hospital ever too small to use the primary care concept? (we have a 30 bed capacity with average census of 15). Does everyone modify it to work for them? Did anyone experience growing pains with the change, like resentment over loss of "class system" among the nurses?

Thank you for any insight you could share. :kiss :)

ceecel.dee, MSN, RN · Oct 30, 2002

I don't think the ratio's will be the problem.

I'm more worried about how the RN's will view their role change. We employ RN's (quite short of these), LPNs (thank god for plenty of these) and CNA's. The LPN's and aids do pretty much all of the patient care and the RN's (typically 2/shift) run around trying to cover everything it takes an RN to do: one is assigned to charge (we all rotate this role) and the other covers ER, OB, ICU when it's open, IV starts, IV push meds, assessments where needed, admits....you get the picture.

My concern is, if the second (and sometimes third) RN is assigned patients, who will have time for all the extras? It seems to me that we will still need this "floater" who is free to cover for the unexpected. This will actually take more nursing hours and budget have to be considered. And, when all RN's are used to charging, how will they adapt to reporting patient info to THE charge, as one still needs to oversee all and have the big picture. The DON does not want to "promote" a few to this designated position as "we have so few that they all need to be able to fill this position, stay familiar with all tasks, etc."

Is a hospital ever too small to use the primary care concept? (we have a 30 bed capacity with average census of 15). Does everyone modify it to work for them? Did anyone experience growing pains with the change, like resentment over loss of "class system" among the nurses?

Thank you for any insight you could share. :kiss :)

llg, PhD, RN · Oct 30, 2002

I sat on my first committee to implement "Primary Nursing" as a staff nurse back in 1978 -- and I have worked in many hospitals with variations of "Primary Nursing" since. Primary Nursing as I have known it, is always modified to fit the specific setting. People throw the term around a lot -- with each person meaning something a little different. In my experience, that is where some of the biggest problems develop.

As people try to make Primary Nursing work in their setting, they encounter some problems and then they make adjustments. As time goes by, the system is adjusted more and more to accommodate the specifics of the setting. That is all well and good. However, as the practical day-to-day issues get addressed, there are rarely discussions of the deep-down issues that underlie the model. As each individual has differing views of these deep-down issues, people can end up being unsatisfied with the resulting system because those differing views of the underlying issues were never brought to light and resolved.

For example:

Take the issue of "continuity," one of the hallmarks of Primary Nursing. How does your staff really feel about this? Do your current scheduling/staffing practices promote continuity or not? If it is a core value of your staff, are those people willing to make some sacrifices in their personal lives to provide true continuity? If your staff sees Primary Nursing as a way to "fix" current problems with continuity, are they going to be disappointed when they realize that Primary Nursing won't fix all of the problems? On some units, having high percentage of part time staff members and staff working three or four 12-hour shifts per week actively works against continuity (and Primary Nursing won't fix that?) On other units with quick patient turnover, 12-hour shifts may promote continuity. In other words, if continuity is an issue on your unit, your unit should be discussing the specific details of continuity on your unit -- not relying on Primary Nursing to fix it.

Another, even thornier issue is "accountability." Are nurses willing to be accountable for things that happen when they are not there? -- or for the care that other nurses give when they are not there? Is the Primary Nurse willing to write out detailed plans of care to be followed when she is not present? Are the rest of the staff members willing to follow that plan? If the Primary Nurse is NOT accountable, then it's really a team of people who accountable, is it not? --- then why not call it a variation of Team Nursing?

These are just a few, quick thoughts -- that might not make a lot of sense at first. I hope you can see what I am getting at, though.

llg