Primary Care or Relationship based nursing in PICU

Pediatric Critical Care Columnist · Mar 11, 2010

The primary care model utilizes a group of nurses who work well together and can provide consistency for the patient and family. So if you were a primary nurse for little Joey, you would be part of a small team that might include Susie, Tina, Barb, Kim and Karen. Whenever you're scheduled to work, you would be assigned to Joey; if more than one of you were on the same shift there would have to be some discussion as to who would take the assignment. You would report off to another team member and the care would be consistent. In situations where you only have a couple of people who have agreed to primary care for a patient, you and your counterpart would be the "case managers", the ones to keep track of what has gone before and what the plan for the future is. You would provide direction to the others who are assigned to Joey.

The unit I currently work on does not have a formal primary care arrangement. The unit manager asks for volunteers, usually for patients with "difficult" families rather than due to complex care needs. Assignments are usually made willy-nilly... I seldom have the same patient two shifts in a row. And even when there is a primary care list for a patient, the "needs of the unit" will always be first in the consideration of a person's assignment. In fact, some people have said that they sign on for primary care to ensure that they NEVER have that assignment. So it really doesn't work well for us!

EastCoastLA · Mar 11, 2010

Great input janfrn. Anyone else use this model of care and have it successfully work? The needs of the unit would always cause change in the assignment and the primary nurse/team can only be spread so thin. Keeping track of the team, probably a project in itself. Any success stories?

ittybabyRN, RN · Mar 11, 2010

I work in a NICU where we have primary caregivers although no real policy for it or system as described above. Basically nurses can choose to sign up to be a consistent caregiver for an infant and would then take care of that infant each time they were working. If two primaries were on the same shift they would work it out somehow. However things also do always change based on staffing, acuity and actual location of the pt (we have a large, private room unit). For the most part though primaries usually get their pt.

Pediatric Critical Care Columnist · Mar 14, 2010

When I first started my nursing career I worked in a Level II NICU (intermediate care nursery) where primary care worked very well. In the two years I worked there I had several "primaries" where the relationship between the family and myself became quite comfortable. When you care for a patient every shift for a month or more with the same people taking over from you, you develop strategies to provide consistent care and consistent messages; it makes everything work better. It's essential to have the trust of the parents in order to create a team and one of the best ways of developing that trust is by giving them consistent information. Where I work now there is no consistency between physicians in what they tell parents so the work is an uphill struggle, especially when we know the outcome will be poor.

In the PICU environment the long-stay patients are the ones who would benefit most from this consistency. In an ideal world the primary team would develop a "schedule" for the patient to build consistency into each day, with a poster describing the routine posted in the room to assist with maintaining the routine. Up at 8, physio and OT at 9, rest period from 10 to 11, dressing changes at 12, story time and music therapy from 13 to 14, rest period from 14 to 16, visit from sibs from 18 to 21, bath and bedtime routines from 21 to 22 and then lights out for example. The tough part is gaining cooperation from other disciplines. One unit for technologically-dependent children I worked on used this model to great effect.

The easiest way to develop a primary care team is to have a unit where nurses work a consistent shift pattern or master rotation. That way the same nurses work opposite each other on a regular basis and can maintain the team relationship. The special care unit I mentioned had a four week, four group rotation. A primary team would have one nurse from each group which kept the momentum up. I would report to Rosa for 3 shifts and Rosa would report back to me. Then Kathy and Donna would work their stretch while Rosa and I had our days off. The following section of the rotation I would report to Donna while Rosa switched off with Kathy and so on. Where I work now, there are no groups and scheduling is a free-for-all so creating that sort of cohesiveness is very difficult. But when it works it's a thing of beauty!

EastCoastLA · Mar 14, 2010

I work in unit that practices self scheduling so everyone schedule is very random and unpredictable over the long term. I would think every person on the care team would need to plan the patients primary team staff about 3 to 4 shifts in advance, to assure primary coverage. The assumption is that patients are long term or in the PICU greater than a certain numbers of days, before a care team would need to be formed. Average length of stay is 4 days in the PICU so 2 weeks would seem ideal. I can see the benefits to the family having the same familiar group. I worry about burnout for some members of the team and also when no primary is available. Building the system to support the sick calls, moving the primary to run charge, or a skill set they have the causes them to take another assignment.

Great and very helpful input. Anyone else with a formal system in place in a 12 self-scheduling PICU?

blueflower77 · Jul 29, 2010

I work in a 24 bed Cardiac PICU and we have the primary care nursing model. I believe it works well for us. Generally what happens is in report, the charge nurse reads off all the patients, then says if they are paired or not, then goes through the pt list and pre-assigns primaries (nurses who have signed up for a pt) and then asks the orientees (if any) which patient they want. After that, the rest of the nurses pick as the charge RN reads off the pt list. Usually, if an orientee wants a pt that has a primary pre-assigned, the orientee goes with that primary nurse. No one usually complains unless the same long-term pt has many primaries that are on that same day/night.

For the most part, people communicate well between each other and our families like it.

ps: usually, it is customary for the nurse to ask the family first if they are ok with her being the pt's primary, then tell the charge nurse. Once one has signed up, only a supervisor can take the primary's name off to avoid situations like someone taking a particular pt ONLY when they are super sick and taking their name off when the pt is better and jump to another sick pt. It's easy to sign up but takes work to get yourself off the list.