Need Help with Primary Care Nursing in NICU

Jolie, BSN · Feb 6, 2009

One of the very best examples (in my experience) of primary nursing in the NICU is Rush University Medical Center in Chicago.

I think it would be worth your while to contact the unit manager or educator there and ask if they can share their guidelines and policies.

Good luck on this important project!

dawnebeth · Feb 6, 2009

I am a huge fan of primary nursing--I always have a 'primary' baby, as often as possible.

In our unit, there is a list with each baby's name and three boxes beside it for each shift. If a nurse chooses to primary that baby, she just writes her name in the appropriate box. Then, when the charge nurse is doling out assignments, she always makes sure to check the primary book to see if that baby has a regular nurse. Sometimes, if there are too many primaries in the room (our unit is very gung-ho about this, so there usually are), then some shuffling has to be done. Maybe Mary gets her primary today and because Sue's primary is paired with it, she also has Sue's--and perhaps the next day, Sue can have that assignment. But generally, it's not that complicated--and it is wonderful to follow a baby from when he comes in until he leaves.

It is entirely voluntary on our unit, and some nurses do not do primary care, but I'd say over 50 percent do. It is more difficult for those who do transport, charge, ECMO and other duties like that because they may not get their primary very often. Some babies have a main primary nurse and an alternate (often a nurse who works short hours) so that if things are coordinated well, there is a primary on nearly every shift and every day. This may require a little calendar between the primary nurses. Although, with my current primary baby, our schedules just fell so perfectly that the baby has very consistant care almost all the time without any discussion between all five primaries!

There is almost no downside to primary nursing--the parents love the consistancy. The babies benefit from having a nurse who understands their particular little quirks. I think some of these babies feed better with someone who knows just what nipple they like, how to be held, etc. If your baby is ventilated, then you may know that he really needs frequent suctioning with saline, or that certain medications always make him puke and can plan for that.

I once proved that my primary was sensitive to vitamins! This was a big, full term drug withdrawal baby who was completely off morphine, except he seemed to come unglued on nights and need a dose. Every evening, I gave him his vitamins. So, one night, I didn't--and he slept well that night, and every night after the vitamins were DC'd.

Primary nurses see the big picture and learn their baby's cues. They form a stronger relationship with the baby and the whole family. Stress levels are diminished (for all concerned) because the nurse comes into the shift knowing what she needs to do and ready to get to work without floundering about.

Dawn

Sweeper933 · Feb 6, 2009

I definitely agree with what DawnBeth said.

My unit has done primary nursing since it first opened 40 some odd years ago. We keep cards at the bedside that have lines for primaries and associates. When you pick the baby up as your primary (or associate), you put your name on the card. There is also a list kept on the assignment board so that the charge nurse can quickly glance at who follows who when making assignments.

We pretty much handle the day-to-day workings of it just like the previous poster. When there is more than one primary on the same shift, we work it out as to who gets them that day. The baby I'm taking care of now as a lot of primaries, so he as a little "calender" attached to the primary list on the charge board. That way the charge nurse knows exactly who to assign to him at all times.

We try on my unit to make sure that every baby has at least one primary or associate nurse signed up for them. A lot of the time, if your primary is a sick / vented baby, then you end up signing up as an associate for the easier baby who is always paired up with them. Some nurses on the unit like just having a few different associates and roaming between them when the primaries aren't there.

The parents really enjoy primary nursing. They always sleep better at night knowing that their little ones are cared for by somebody who is not only qualified, but who knows them well.

Feel free to PM me for more specific information!

oglesbymom · Feb 8, 2009

Thanks for your replies!! Does anyone have your protocol or primary care outline or anything that I could present to my unit as an example (from another hospital). Or possibly contact info for the person at your hospital that can send me that info. Thanks ya'll I really appreciate your help!!

dawnebeth · Feb 8, 2009

I will look today to see if we actually have a protocol. I don't know! lol

Dawn

RN4Little1s · Feb 16, 2009

I was actually going to ask the same question, and I noticed this today! Our unit has always had a place to sign up as a "primary" for a baby - we make our own assignments together at the board in each room at the beginning of each shift. However, the unit felt that this list was often ignored because a nurse who cared for a baby for 2 days would sign up for the baby on her 3rd day even if the primary nurse showed up. So the primary nurse would take a different assignment on that day and continue to to take the random assignment the rest of her week... But in general, this system worked out just fine. A few people wanted to improve the way we do things - set "rules" into action about being a primary - and now there is a lot of complaining going on.

Each baby is to have one primary for day shift, one for night shift. You must work full time to be a primary. Every time that person works, regardless of how many days the other nurse has been caring for the baby, she gets the baby. You can sign up to be an associate, but the primary always trumps. They are encouraging the first couple of nurses who take care of the baby when he/she is admitted to be the primaries.

I believe you become a primary by bonding with the baby, loving to take care of the babe's particular diagnosis, developing a wonderful rapport with the family, etc... Just because you admitted the little one, doesn't mean you would be the best primary - it just happens. Secondly, by just having ONE primary and making others always give that assignment back to you the 3 days per week you are working - I feel like the baby misses out on some lovely consistency of care (he needs a couple more primaries) which is the whole POINT of primary nursing! We have to do the trial as it stand right now, but I am interested in finding some ways to change plan a bit. I actually didn't mind the way we did it before - the only thing I would want to add is being able to follow a baby to our "transition to home" rooms at the end of their stay if we wanted to. Any thoughts?

oglesbymom · Feb 17, 2009

I thought of another question about this last night. How do you have primaries and orient new nurses. At our hospital, when a new nurse comes, he or she is assigned to one nurse (preceptor) for 12 weeks. So does the preceptor get dibbs on the sick babies over the primaries?

I talked with my director about this and the 1st Monday in March, I have to submit a proposal to the Safety Counsel and see what they say. Until then I will be gathering as much supportive info as possible, so if you have any examples or protocols or "rules" or anything, I would really appreciate it!!

Thanks guys, I love having a place to talk with other NICU nurses that know what I'm talking about! My husband looks at me like I talk in tongues when I talk about work =)

RN4Little1s · Feb 17, 2009

For us, in general the preceptor/orientee duo has first choice of the assignements no matter who had he/she the day before. However, if the kid is REALLY sick, then the primary will most likely take him/her. No hard and fast rule on this.

oglesbymom · Feb 17, 2009

Are there any draw backs to primary care nursing? Any problems you notice?

RN4Little1s · Feb 17, 2009

Sometimes the families and nurses get very close, and there have been family members who have taken advantage of nice nurses - saying "oh XXX other primary let's me read the chart whenever I want" (we are to have an MD present to answer any questions if they want to read the chart) or "XXX other primary let's me bring in an extra visitor." Also when families get attached to certain nurses they start to almost demand that they are there for their baby. They will state, "No, Laura said she would be here." When told that Laura called in sick they may get upset (even CRY!) and take it out on any other nurse who cares for the patient. Basically, they become emotionally dependent on just a couple select people and are unable to cope with other very competent, awesome nurses caring for their baby, learning about them so that more than just 2 people know about them... That is all.

HealthShepherd · Feb 19, 2009

Whatever other decisions you may make, please be sure to keep primary nursing voluntary on the part of the nurses. There is the occasional family that is very draining to work with, and I think it would be very unfair to assign them a primary nurse without that nurse volunteering for the job. The unlucky nurse would be dreading every shift for weeks or even months, which would make burnout much more likely.

Having said that - I think that one of the possible drawbacks of primary nursing relates to equity. The children of nice people get nurses volunteering to primary them, and the children of obnoxious people don't - so some babies get better care than others. I see this problem, but don't know how to remedy it, because I think that forcing nurses to work every shift with unpleasant parents is the greater evil.

Another suggestion for introducing primary care - keep a list of which nurses have which foreign language skills or special affinities for certain diagnoses (e.g., a nurse who is the parent of a Down syndrome child may be especially good at working with the parents of new Down syndrome babies). Then, when a new baby is admitted, the charge nurse can scan the list for a nurse who might be an especially good match, and let that nurse know that's there's a new kid who might be a good match for them.