Nursing Care: Team nursing vs Primary nursing care

[TamIam]

I am curious to know what others' experiences are in their practice. Where I am employed is currently changing from a Primary Nursing Care approach (RN's doing most of the care/assessment/etc) to a Team Nursing Care approach (One RN to 13 pts, with LPN and PCT assistance). My understanding is that the RN is 100% accountable for the work done by the LPN and PCT. Has anyone had experience with this? What are the pros/cons that you have seen/encountered?

[pickledpepperRN]

Try to keep primary nursing. The RN is always responsible for the nursing care of each patient

An LVN/LPN is a licensed nurse responsible for providing nursing care within their scope of practice and reporting any change in the patients condition to the RN.

The hospital is responsible for the competency of the PCT. So long as the RN only assigns tasks in their job description they are responsible for performing these tasks correctly.

Watch out that the PCT job description doesn't include tasks unlicensed assistive personnel (UAP) are forbidden by law. Hospitals have done this and it is NOT legal. That is why I think the minimum education and training for patient care shoul be certified nursing assistant (CNA).

[FreshRN05]

In our unit, we do TPC. Nurse-patient ratio is 1:5 with a Nurse Tech being shared by all 14 patients, a CN, and a monitor tech/secretary. Our unit in the hospital is brand new, we call it an holding area for patients who are either waiting to be transferred to anohter unit or to be discharge. It's a 14 bed unit. We basically monitor patients that do not have severe illnesses or infections (we don't have an isolation room and all of our equipments are portable)...Now if the unit only have 5 patients, then no tech will be assigned; 1-10 patients, 2 RN's, CN, secretary, and one Tech..This is a med-surg/tele floor, by the way.......Now on the other units in the hospital...they do team nursing...nurse-patient ratio is 10:1 (med-surg), 1 RN, 1 LVN, and 1 Tech....7-8 patients (tele floor) 1 RN, 1 Tech and 1 LVN....I oriented on these floors, I actually liked it because since the LPN does PO meds, dressing changes etc...it gave me more time to really assess my patients and do my plan of care and of course charting...I decided to do TPC because I'm a new grad/new RN with no previous experience, doing TPC will make me see the whole picture of my patient's condition and practice skills that I only got to practiced on dummies while in nursing school...but eventually once I am more comfortable with my skills and critical thinking skills, I'd love to go back to team nursing.......I'm just getting my experience now.

[flasandy42]

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I'm an LPN and have always done total patient care. I prefer doing all my treatments and giving my own meds so I know what they've had. We tried Team Nursing for awhile with an RN, LPN and CNA on each team....and where the team leader gave all the meds for the team, but it didn't work out. There were 20 pts on a team and it wound up with the LPN who was with the pts the most was doing most of the charting. It's hard to chart when you haven't really taken care of the pt. With TPC nursing you're doing everything for the pts so you are aware of what's going on. The CNA helps with baths, light and I & O's.

[Nancy2]

I have done both primary and team nursing. I find benefits and difficulties in both models. LVNs practice according to the scope of practice determined by the Board in that state. Most can practice fairly independantly but must be under the diredtion of an RN or Physician. I know a lot of RNs feel that it's "their license on the line" if an LVN makes a mistake. That is only true if the RN directs the activity that turns out to be a mistake. It's important if you are working on a team that you understand the scope of practice for the other team members, so you don't direct someone to do something that is not supported by the law of your state. It's kind of nice to have the ability to delegate some care so that it all feels more manageable. It really comes down to the calibur of the team as a whole as to how well it works.

Best wishes to you in your career!

[Hoozdo, ADN]

TamIam said:

What are the pros/cons that you have seen/encountered?

One con that I recently experienced is team nursing with no team. Nine tele/med-surg patients....some of whom were very ill with no LPN and no CNA. I was only floating through this area thank GOD. Team nursing does not work if you have short staffing

[RN130]

MY experience is that Hospitals make the "Nursing Model" changes with the goal of saving money. So beware, get nurses to look at the plan and the patient ratios as well as acuity. Be clear about the scope of practice and each persons responsabilities.

[speti4]

I work as an LPN in a 20 bed med/surg/mat unit. We do primary/total care nursing.

We have 2 LPNs and 2 RNs on 0700-1900 shift. On 1900-0700 shift we have 2 RNs and 1 LPN.

The pt. load is split between the 2 RNs and one LPN, with any tele pt. going to the RNs. The extra LPN floats. LPNs take turns floating which works well as it gives the float a break from meds, etc.

As a float I chart all the procedures and PRNs I have done. I will also take new admissions throughout the day if the other nurses are swamped.

Here, the LPN scope is broad enough to handle most of the pts that we get. We are 100% responsible for our own errors. We do not work under anyone's license but out own. If as a float we make an error on another nurses pt., we are 100% responsible for it. If an RN delegated a task to an LPN and the LPN followed exact instructions and it caused an error, both the LPN and RN are each 100% responsible for their error.

As an LPN I must know my scope and any medication or other procedure I perform. We all know that we have to practice and chart smartly to cover our butts. Canada is not as letigious as the USA but I think we are on our way.

[AussieKylie]

I feel whilst working as a PCA in a team nursing environment that there is a possibility it can work if enough staff . Otherwise when its 1 RN, 1 LPN and 1 PCA assisting totall 10 patients, 4 patients who are full assist x 2 people, and the other 6 are manageable I find it cant work because the RN and LPN are trying to still do pill rounds, wounds, discharges, admissions, so when its me needing assistance with the full assist work load gets behind and I get frustrated. The worst case scenario is myself as PCA with only 1 RN with 11/12 patients and most are full assist. Team nursing to me is sharing the load and working together to meet goals. Only if there is enough staffing then it will work but going from my examples, I come home burnt out big time and its not right especially when I will be hopping my way in to my Grad RN role in July this year.

[Brent Parry]

Back in the late 80' s into the 90's we did Team Nursing in a 50 bed Med Surg/Ortho unit. Teams were split into 25 Patients per team. Had (1) RN Team Leader/Charge Nurse who called the docs for updates/orders. Had (1) RN as Med Nurse and (3) LPN's, (1) NA who would divide 25 Patients among the (4) even the NA had their own assignment of lower acuity patients. The TL/MN nurse were responsible for admission assessments and the NA charting as a cosignature validating care delivered. So the minimum in days/eve shifts required 4 RN 's 6 LPN"s 2 NA's to cover both teams 25/25. This system worked well. Then we changed to "Modular Nursing" the floor was split into (4) Mods. Each RN took a Mod as TL/Chg Nurse and acted as Med Nurse too for the most.  Mods 1,3 had 2 LPN's Mods 2,4 had 1 LPN 1 NA. So the mods had 12 to 13 patients split into 2 direct or care assignments with the RN covering Charge and Meds. Night shift was a *** show; 2 RN's 3 LPN's 1 NA so 3 staff per 25 Patients if we lucky. Most nights it was 2 RN's 2 LPN's 1 NA so 5O patients were split 3 ways leaving anywhere from 14-16 patients assigned for direct care while the 2 RN"s split 25/25.  Then when census would drop into the 40's or less we would dropped to 4 staff. 1 RN, 1 LPN for mods 1&2 1 RN 1 NA for mods 3&4. The NA functioned more like an LPN with RN oversight (LOL) It was a war zone. Best experience ever but man we ran out butts off. Call lights, turning pts, suctioning, vital signs, accu checks, meds, charting, and the frequent Codes because there was no RRT back then. We managed every unstable event on the floor unless we called a code. What an incredible group of nurses to work with. Smart and worker bees who helped everyone. Brutal night shifts were quite exhausting. Never punched out on time and no dinner breaks. I could never do that again at this age. Ultimately spoke up against the poor staff and unsafe environment and got pushed out the door by management. Can't have anyone speaking the truth.