Primary Centered Nursing

[JenniferBSN]

I am an RN in a Level III NICU. We are piloting primary nursing in our unit. We are trying to find literature or talk with other nurses that are using primary nursing in their units. If you know of literature or are using primary nursing in your NICUs please e-mail me. Thank you.

[NICU_RNwantsFL]

Hi - we use Primary Nursing in our unit.

Nurses have the option of signing up on a particular infant, then whenever the nurse works, she is (at least theoretically) always assigned to that baby (in addition, of course, to other babies so as to make a full assignment).

Lots of our nurses don't sign up to be primary nurses because, for a chronic kid like a BPDer, you are stuck for weeks (months?) on end in the continuing care section of the NICU, where you might be assigned as many as 5 babies who are supposedly PO feeders but don't have a clue how to eat. Gets frustrating, and most of those nurses prefer the "action" up in the most intensive section.

I have had several primaries, and I can say I really enjoyed them. Of course, it is most beneficial from the baby's standpoint, because the same nurse caring for him that regularly is more likely to pick up on subtle changes that a new-to-that-baby nurse might not spot. Parents seem to like it too, because they can deal with the same nurses and develop a commaderie with them. Of course, by getting to know the family over time, the nurse can also pick up on any social issues that might need addressing.

[wjf00]

We have primary assignments where I work. I don't like them because there are nurses who use the primary nurse to keep 1:1 vent assignments, then drop the primary as soon as their assignment goes to intermediate. Seems to be used a lot to keep 1:1 assignments only.

[Gompers, BSN, RN]

We use primary nursing and really love it. It's entirely voluntary, and "dropping" a baby once it's not sick anymore is really really looked down upon, so it doesn't happen very often. We try to make sure each baby has a primary nurse (any shift), and then we can also sign up to be associate nurses to take care of the baby when the primary isn't there. Some babies have up to 8 associates!

We have a big board where all the babies are listed, with the primary nurse's name next to it and then the associates after that. The charge nurse takes the assignment sheets for the next day to the board and pencils in primary and associate babies next to the nurses' names. Of course they try to assign all the primary nurses to their babies first. Then they pencil in the associates, and these are given second priority. If there are multiple associates on for a single baby, the one whose name is further up the list (signed up earlier) gets first dibs. If a baby's primary won't be in until evening or night shift, the baby is assigned to someone who will be leaving when the primary comes on. It works out really well, considering that we do 4, 8, 12, and 16 hour shifts.

Primary nursing works really well for us, as we enjoy continuity of care and feel that it really does help in terms of picking up little changes from day to day. The parents really love it too, especially because we do associate nursing as well. It seems that some babies almost always have the same nurses, day after day, and the parents have said that it makes them feel so much more comfortable. Of course, there is a downside here - it makes parents really wary of "strangers" sometimes. You have to explain that it's an ICU and that they won't always get "their" nurses but that everyone is very qualified even if they don't "know" their child.

For me, it makes me excited to go to work to see "my" babies and how they're doing. Because we've bonded with these babies and their families, it makes such a lasting impact on them. Parents say it intensifies their rollercoaster ride in the NICU to have someone familiar to celebrate with or to greive with. They know that we spend more time with their children than anyone.

[neominder]

we have primary nursing in our unit. it is completely voluntary. i love it, and almost always have a primary pt. we also have associates who care for the baby if the primary isn't there. either a nurse can sign up for a primary, or parents can ask to have a nurse assigned to thier baby, but it has to be acceptable to both nurse and family. a primary follows a pt through the nicu stay, when the pt moves to level ii they will then pick up a new primary nurse form the level ii staff. those of us who primary love it, and those who really like all the adrenaline don't they just take care of the super sick kids w/o primaries and do admissions...

[nurseiam]

We dropped primary nursing about 2 years ago because there was no real system and people would sign up for a 23 weeker then drop it after the CLD kicked in. Or the best families had a great team and the difficult families had no one. I really miss it. I had several that I followed from 23-26 weeks through discharge. So I am intrested in the same thing and getting it started again in our unit bt we need to come up with a better way.....Previously it was voluntary also but people always try to take advantage in every situation. In our ICN nurses would sign up for two(which was okay, but they may not get both) during their 6 day stretch then take themselves off until their next stretch.

[disney65rn]

We have a well established primary system at our facility. We have worked out most of the kinks over the last 7 years or so. It is nurse governed and runs well for the most part. The issue we have run into lately, is the (over) attachment some nurses develop with the patients. Has anyone else faced this and if so, how has it been dealt with.

[BittyBabyGrower, MSN, RN]

We are the same as Gompers, and no one ditches their primaries after the acute phase is over. They will take a break from their kid every now and again, but no one drops them.

We get the people who have the over attachment also, personally, this is my job, I don't take it home, I don't hand out my phone number or go to people's houses. As long as it isn't interfering with the child's care, we don't do anything about it.

[SteveNNP, MSN, NP]

We have used primary nursing for the past 15 months, ever since our new nurse manager arrived. The downside is that you can have the same babies for 3 shifts in a row, only to lose that assignment when the primary nurse comes in on that last shift. It can break up continuity of care. We attempt to minimize this by having only nurses from different shifts and track schedules sign up for the same primary. We are not allowed to drop a primary, and if you don't sign up for one, the NM threatens to assign you a baby that doesn't have a primary. While there was a lot of grumbling at first (esp from us charge nurses who have to break up assignments all the time) the staff really enjoys it now, and have become "possessive" of their babies in a good way. They keep the rest of us accountable for what happens to "their" baby while they are off, and often provide better family-centered care having interacted with the family for so long. We also choose up to 3 associates along with our primary. I typically choose the scrawny wimpy white boys who suck at eating. I just find them so irresistably cute. I also choose my primary based more on the family than the baby... that can make or break an assignment you're essentially stuck with for 2-4 months..... (we can take breaks from our assignment if we need to. Of course charge, precepting, and transport nurses do not always get their primary depending on what's going on in the unit. We have had a crazy month recently, after being at about half-normal census since Christmas. (and opening our newly expanded unit.... go figure)

[rnpilot]

I started using primary and associate nursing in the early 80's and did it for probably 10 years between 2 hospitals. I've worked several other places that didn't use it and was disappointed. I, too, loved the system. Usually, we became the primary on admission. It was an expectation that we always had at least one, and we couldn't drop them. We could take breaks, as well as wait until getting an admit to take one. Evey baby had to have a primary within 24 hours though. I don't think this system is as important in small units where everyone knows all the babies anyway, but it's fantastic in the big ones to insure coordination and continuity of care.

[crissrn27, RN]

Well I work in a mostly level II nursery and we do primary nursing "unofficially". This is good in many ways, as the family and baby usually have 4 regular nurses during the majority of their stay and the continuity of care is better. The down side where I am is the same nurses want our feeder/growers all the time, and other nurses never get a chance to work with them.

[kitty29]

Our hospital is implementing a new nursing model called Relationship Based Nursing...it's an extendsion of primary nursing - more defined & holistic.

I tried to get comments on it a couple of weeks ago seems no one had any ideas. Should be interesting.