Nursing Care Delivery Models??

[rck213]

Recent nursing satisfaction surveys have finally prompted our facility to look into a different way of administration of nursing care. For the past 15 years it has been an undefined mess of whatever some "Service Line Manager" felt would work at the time with the minimal nursing staff the facility budgeted for. There was NO input allowed from the staff nurses and for many years no director of or vice president of nursing services.

A nurse practice committee has been set up to decide what care delivery model should be used and also to completely redo the mess made of the policy and procedures for the facility.

Looking for ideas of what does and doesn't work and why.

[Repat]

It is great to see that someone is trying, even if it is to try to sort out a mess! But I think the first place to start is with the people at your facility. I would be interested to hear what they have to say.

[rck213]

I am asking because at the first meeting no one had any idea of what the possibilities mean. Too many years under a dictatorship and many newer RNs had never experienced anything else!

A consultant was running the meeting. She mentioned magnet, primary and team. In team nursing she stated that the unlicensed personnel had their own patient assignment which meant the RN on the team could care for more patients....example, if ratio usually 6 pt to 1 RN it could become 10 patients if using an aid to assist. Doesn't sound quite right to me!

The consultant did say the committee members would have to contact or visit facilities using various models to get an idea of how they work. When this will occur is unknown.

Hard to trust after so many years of abuse.

[fergus51]

I HATE team nursing because of this. It usually means you are responsible for a whole schwack of patients and if you and the unlisenced personel aren't on the same wavelength, you're dead.

I prefer primary nursing and work with that model. I have my own patients and am completely responsible for them alone.

[pieWACKet]

I apologize , and tried to edit this response. It is likely more than you wanted. I can not delete it, and so must leave it as I gave it. I recognize that your effort here is to seek nursing models. This diverges somewhat.

Your first post indicated you were in the unique position involving a committee to reverse the autocracy of the hospital environment in which you work. The second indicated that you are currently considering magnet, primary and team.

I have comments on primary, team, magnate and the role of the "consultant" you mention

First, I'm confused. I know what team and primary nursing are, but magnet...[PLEASE tell me if I am wrong] this is a term I recognize as referring to "magnet hospital" status. Magnet hospital status is relatively new ...conferred by the ANA to hospitals more able to retain and recruit nurses in their local environments. Often, these hospitals include day care at their facility, self scheduling, response to nursing concerns, etc. The pay scale of magnets don't seem to be above those that aren't in their regional environments...what varies is the report among the nurses there employed, evidenced by a lack of recitivism, of the treatment of nurses by the hospital of employ. Magnet hospitals are mentioned much in legislation regarding nursing in regards to methodology in the nationwide effort to decrease the shortage. They are studied and referred to in regards to what hospitals with "magnate" status do that encourages a decreased local recitivism and vacancy rate , despite the reality in other regionally close hospitals with far greater recitivism and vacancy despite similar JACHO standing.

So, for me [am i missing something here?] the consultant [as an aside I would be VERY interested in the degree and employment background of this key player on your committee- i think NURSES should run this committe and a "consultant" be the guest] mentioned primary and team nursing and then another thing entirely, magnet , the definition of which as I understand as given above. This means that i understand that your consultant is aware of magnet hospital standing and desires to gain it.

I am going to ignore primary vs team and focus on magnet and what I think you are in the unique position to develop.

Here's my imput.

Bring to the group this discussion [ i have mentioned this in many other posts]. ALL surveys regarding the shortage and its roots, whether conducted by the ANA and allied groups or the AMA [American Hospital Association] and its allied groups, find TWO primary causes for nurse dissatisfaction leading to the current crisis shortage. The first has to do with inadequate response to market demand generally placed first in the NURSING evaluation of data of polls [that is: inadequate pay for work expected/performed-best stated as pay scale deficit]. The second are environmental factors more often put forth as primary on evaluation of the data by the hospital associations [who want very much to avoid increased pay] involving many complaints best described in aggregate as lack of voice [you can refer to my incomplete and ever expanding pages on the nursing shortage at http://www.cynthiaswope.com/ABedsideRNPerspective/TOC.html if you like where much discussion and documentation is presented].

Nurses often seek radical voice as a result of nursing's lack of voice, shamefully present for nurses throughout the health care system. Radical voice currently takes the form of unionization, where environmental and wage factors can be addressed through contract. Tired of being ignored, bedside nurses seek unions in order to have their voice heard. Hospital administration often seeks to undermine unionization efforts.

YOUR MOST RADICAL and MOST INFLUENTIAL request of this committee, is for it to consider and demand the meaningful involvement of a bedside RN among the board of directors. THIS IS TRULY RADICAL. All hospital boards include an MD practicing in the hospital upon its board. WHY do not nurses, representing 70% plus of the labor resource pool of hospitals, NOT enjoy a similar position? Hospital boards that boast RNs [and those that do boast them loudly] have RNs long aligned to management and way removed from the bedside nurse. In my vision, this bedside RN on the board would be elected by the BEDSIDE nursing staff...would enjoy a year long appointment contingent on continued full time employment, and would absolutely NOT be in management. A vote for that member would have to be sought of the bedside nurses, who could be encouraged to choose that member much as we citizens choose our elected representatives in local, state and federal elections...that is , through evaluation of their stands, their vision, and through debate.

I am glad for you having a committee to address these weighty problems. This is a very positive step. But I am wary that there is a "consultant" from whom you are, by her/his title seeking direction. In the worst case scenario, this person will get your committe to agree to a program nearly predetermined, the choices of which were already formed. It occurs to me you are in the possible position of providing, through your agreement to any "suggestions" [ whichever ones you choose, and dismiss without offering your own] provide a false sense of security regarding real change that could really initiate a change in your hospital. It is my feeling you should demand of this committee that it allow NURSING to present the options desired, and that much more than a commitee is needed. Real imput from the nursing staff is demanded, and only an elected voice in the position of leadership will suffice [hearkening back to the board of directors RN]

If i were on this commitee, I would want to addressnursing voice, at the bedside {how nurses are treated, how their concerns are responded to, how they are interacted with, and their involvement in patient care decision making} , in the unit {what kind of nursing, team or primary is predominantly practised} and in the hospital tier {is there really an outlet for effective voice and someone in a position of authority and power able to address and respond to the ongoing concerns of the most vital portion of the hospital, its nurses. The the primary reason why patients are admitted to hospitals is the promise of nursing care.... in the ER, OR, Recovery, ICUs, floors, etc] . Remember this: patients are admitted to the hospital because of the promise of nursing care there. Make sure that this thought is presented.

That's my two and twenty odd cents worth.

[rck213]

Thank you for the honest discussion. My fear also is that this is a blind exercise to show that administration is encouraging "nursing" involvement but all along the course has already been set by administration and they are trying to make us think it is our idea.

Add to that the fact that the current "acting" VP of nursing services who was one of the "Service Line Managers" who stabbed every bedside nurse in the back every chance she had so she could collect her year end bonuses. :angryfire ....This person is sitting in on the meetings. There are promises to hire a new Nurse Executive, someone with power equal to the CEO, which this facility has never had before.

But if they fail does this acting VP get the position?

Also there is only ONE actual bedside nurse at the table, the rest are charge nurses, managers, and clinicians.

Looks like there is much to be done and I am still skeptical.

I would still like to know which model, Primary or team is preferred