Primary Nursing is for the BIRDS

[mindlor]

So I am a relatively new RN.....maybe 15 shifts or so being on my own......I get in to work yesterday and see thy have made me "primary" for 4 very sick patients. All 4 strict contact iso, extensive IV therapy, diuretics, laxatives, to the second pain management...the whole nine yards......vents, trachs, dead weight unable to help with their care at all....

I found that during the shift I was basically a half-a__ed CNA and a half-a__d nurse.

Anyone else have experience being a "primary" nurse?

What are your thoughts?

Personally I told them that I won't do it again until I have more experience and that when I do I think 3 pts would be much more doable......

The good news is that I probably lost 5 pounds worth of sweat

[Indy, LPN, LVN]

Is every shift heavy on the total care/isolation patients? Do you have CNA's at all? I was told on my first job to get ready to be "dumped on" acuity-wise for my first year. In reality I didn't find that I felt dumped on all the time, but there were some weeks when it just ... wow, it didn't stop. We had one CNA in a unit that was 3 different hallways, and the tech would be assigned to one hallway so I saw her about once or twice a month. Let me tell you I had to figure out how to work without one!

There was an old post on here years ago where someone recommended to new nurses the "rounds" system for medsurg. Basically it's round one, VS and quickie assessment (you learn to do it fast) and find out what they want to snack on. (This is for night shifts.) If you carry your paperwork with you, check the assessment off and write a quick note outside the room. Round two is starting meds and accuchecks, and with the meds you take the snack. Round 3 is ice the pitchers, bathe one of 'em, toilet the rest, say goodnight. Again after each visit stand outside the room and chart really fast. Then go pee, eat, do chart checks, time for MN vitals and/or toileting. You see how this goes. If you keep up as you go, which is the hard part to learn, it makes it so much easier to finish at the end of shift. And yes, you feel like a halfa$$ed CNA but you at least are getting some of the basics done. It takes a good 6 months to a year to get comfortable.

[CrunchRN, ADN, RN]

Was it doable? who helps turn etc. Is this acute care? I have never heard of less than 4 ratio for acute. Sounds back breaking.

[Been there,done that, ASN, RN]

What was the assignment for the other nurses? When it is necessary to adjust the assignment (usually because we are one CNA short)the patients are lower acuity.

It makes no sense to give the primary nurse complete care patients when s/he will be forced to call the CNA for assistance anyway.

There was no way you should have been trying to turn or clean completes by yourself.

Just because a CNA is not specifically assigned to that patient , you still have to get some help.

[TheCommuter, BSN, RN]

To be straightforward, I cannot stand the primary nursing model of care. I prefer team nursing because some tasks can be artfully delegated to other team members, and everyone is used to the best of their abilities while staying within their scopes of practice.

[BrandonLPN, LPN]

I think the primary nurse model is why so many of our LTC patients come back from the hospital so deconditioned, underfed, unshaven and with bedsores. I realize that the acute illness needs to be the focus in the hospital. But ADLs are important, too. Getting out of bed is important. Turning someone q2hrs does NOT cut it if they stay in bed for almost their entire week long stay. And how many times is a meal tray just plopped in front of an elderly hospital pt who needs assistance or at least prompting? The aides in hospitals don't have enough time to do proper ADLs, they're running around checking vitals, doing fingersticks, etc.

What hospitals need is a return to old fashioned team nursing, with a RN, a LPN and a CNA all on a team. The RN does the assessments, manages care and contacts the doc as necessary. The LPN monitors vital signs and blood sugars, administers meds and performs most of the bedside procedures/treatments. The CNA does almost strictly ADLs. I know a lot of hospital aides will bristle at this, but this will free the aides up to actually provide total care. Obvipsly the roles need to be a little flexible. Sometimes the CNA must help the LPN with the vitals. Sometimes the LPN must help the CNA with the ADLs. Sometimes the RN must help the LPN with the treatments. In other words, team work.

Obviously, a lot of RNs will balk at this because it will result in them taking a larger pt load and taking more responsibility for the work of others. Well, sorry, but I say too bad. Part of the RN role is delegating. The prime function of the RN should be a team leader, not a primary caregiver. And all those who want to see RNs viewed more as a professional should embrace this. Professionals accept responsibility for the work of those working below them. That's what being a professional is all about.

[Altra, BSN, RN]

mindlor, I thought you had quit that LTAC job, I really did.

What you are describing sounds pretty typical for LTAC. Trached, total care is the bulk of the LTAC patient population.

[mindlor]

Hi Altra...

I did quit, but a few days later the nurse manager called me and we negotiated for my return to the job.

So here I am. I have good days and bad but I will say more are good.

I am blessed with awesome coworkers and good management. Those two things make the job bearable.....

[Good Morning, Gil]

Sounds pretty typical for LTAC, which is why it usually has a higher turn-over rate. Sounds like other nurses are helping you non-begrudgingly, though, so that will make it bearable.

[RURN2O11]

BrandonLPN,

I think you have a very good point. I never really considered team nursing in that way, I guess b/c I am too young to have ever experienced what you're talking about. I think you have made several very good points though. I know I would miss some of the one-on-one care w/ the pts if the LPNs were doing most of that but I think you are right that the system you describe would serve the needs of the pts better & would make our lives as staff easier & more enjoyable also.

[Esme12, ASN, BSN, RN]

mindlor said:

Hi Altra...

I did quit, but a few days later the nurse manager called me and we negotiated for my return to the job.

So here I am. I have good days and bad but I will say more are good.

I am blessed with awesome coworkers and good management. Those two things make the job bearable.....

This is the very reason there are such turnovers in LTAC's....do they have any aides at all?

I have run the gamut. I have done team nursing with LPNs and aides. I have done "POD" nursing and primary care. I found primary care for 4 acutely ill step down ICU patients very challenging (we took vents there were no LTAC's then) but we shared an aide for every 15 patients.

I find I have liked team nursing with LPNs and aides the most fulfilling for floor nursing but I prefer the ICU/CCU/CTPACU/TRU for this very reason.

You need to be super organized and some days super human. When I supervised a LTAC I always pitched in for the patients were so sick one nurse couldn't really care for them all well.

But you have something that can't have a value placed....good co-workers and good management. :hug: Chin up!

[RN In FL]

To me.....Primary nursing IS NURSING!!! Some may call it "being a half a** CNA", but if you are organized, with a CNA, then it can be done. If you are scatter-brained and are unable to prioritize....then HANG IT UP!!!, you will dislike primary nursing. I feel the key is to get your patients in order at the beginning of the shift and things will flow...especially on a med/surg unit. J/S