Primary Nursing is for the BIRDS

RN In FL · Aug 22, 2012

SoldierNurse22 said:

Since when did doing CNA duties become "not your job" as a nurse? CNA duties ARE nursing duties, just delegated. Whether primary nursing or team nursing, you're still responsible to make sure they get done.
I love primary nursing. I have the clearest picture of my patients because they're mine, shared only with a CNA. I know everything that happens with them because I'm either there or talking about things with my tech. I am responsible for everything and the overlap and potential for error between caregivers is minimized.

I was floated to a floor a few weeks back where team nursing was the standard. It was so disorganized. My CNA and LPN didn't do their jobs even though we discussed and agreed on delegated duties at the beginning of the shift. If all hell breaks loose and the shift goes down while I'm the primary nurse, I have 4 patients that I am totally responsible. Yes, it sucks sometimes, but it's manageable. If all hell breaks loose in team nursing, I'm totally responsible for 8 patients. The advantage is undeniable, at least in my situation.

Very Very well stated!! I totally agree. Love Love Love primary nursing, and being responsible for my own patients! VS everybody else poking around so to speak.....LOL :yelclap:

Vespertinas · Aug 22, 2012

^^^If only my patient load was reduced by half for every "primary care" patient I received.

I love the idea of primary care too... except when you have the same number of patients as you would on a regular day, you pine for some teamwork.

SoldierNurse22, I'm sorry you had a bad experience with team nursing but it sounds like that floor you were floated to doesn't illustrate what good team care can actually look like.

redhead_NURSE98!, ADN, BSN · Aug 22, 2012

mama_d said:

In my neck of the woods, "primary nursing" means no techs...so the nurse does all with no real assistance. ALL of the ADLs, code browns, feeding, blood draws, I & O's etc. on top of nursing duties. No backup when you have multiple patients on bowel preps or an entire team of fall risk patients.

This. So, some other people on this post need to check all their righteous indignation about the OP complaining she has to be a "half ____ CNA," because that is what she feels she is. She is saying she is not being a good assistant or a good nurse because she feels she can't be both roles with such acuity. She never implied she shouldn't have to do "CNA work" at any time, or that it was beneath her, or anything of the sort.

LilgirlRN, ADN, RN · Aug 22, 2012

There are several different things that an RN and a CNA could both do on the CNA level but hardly anything that can be done by a CNA on a nursing level. You only have 15 shifts under your belt.... you gotta learn to delegate. I don't believe in sitting on my butt if there's nothing that needs to be done on the RN level. I can clean poop with the best of them. The shift you described however shows that your patients had very high acuities. The RN stuff needs to be your first priority! If you have trouble approaching the CNA's in terms of delegation, I would just tell them the truth. You can't do it all, the PATIENT needs their help. Half a$$ anything will get you in trouble these days. I'm gonna assume that you're not the charge nurse. Ask her/his for help. Make sure your manager knows of any problems cause if patients/families start complainingyou may be able to head 'em off the pass so to speak.

Home Health Columnist / Guide · Aug 22, 2012

I started out with team nursing on night shift. Brand spanking new LPN with 2 CNAs for 26 patients. Almost alwways late by 1hr after shift documenting. Survived the floor 2 years then moved to 14 bed respiratory unit: me and 1 CNA if I was lucky. When we added telemetry monitors in 1982 (after I graduated with BSN), became step down unit with vented patients staffed with 3 RN's each 8hr shift no CNA; started bedside rounds and primary care. For care rounds we teamed up with our RN buddy most times to assist with baths, complicated 1hr wound care and transfer vented pt OOB to chair. Enjoyed primary care the most on this unit. Had 95% success rate weaning patients and discharging from facility. one of the best things I liked about bedside report was my minds eye could take in the picture of patient knew which room was left like a tornado swept thru,m which client was ashen and needed immediate assessment, etc. Learned to do basic assessment first rounds in 15 min each patient, then completed during bath/wd care after first med pass. Later did 12 hr shifts weekends with report only taking 5 mins as had the patients night before if it was a quiet shift.

Responsiblity for 6 patients total care as a new RN requires more than 15 shifts for success. Expect 1hr overtime minimal for first 3 months till you can develop a routine and begin to feel like you know what your doing. You will learn many skills working on this unit that will stay with you throughout your career. Plant the seed in your mind that you will be a success, you can do it --possitive vibes do help---along with NEVER mentioning the Q word quiet. I see that you have assertively asked that assignments be equal and not just dumped with all the heavies. Quite often ALL the patients are heavy in LTAC. Learn to partner with other staff to see if you can share heaviest workload together. When you work as a group, one can survive almost anything. When off from work, plan downtime/ relaxing activities so you can decompress.

Wishing you better days ahead.

mindlor · Aug 22, 2012

redhead_NURSE98! said:

This. So, some other people on this post need to check all their righteous indignation about the OP complaining she has to be a "half ____ CNA," because that is what she feels she is. She is saying she is not being a good assistant or a good nurse because she feels she can't be both roles with such acuity. She never implied she shouldn't have to do "CNA work" at any time, or that it was beneath her, or anything of the sort.

Thank for this ? I absolutely do not mind doing CNA work. Cleanup and bathing are great times to assess the skin and change wound dressings. Oh yes that reminds me, all of our patients have complex wounds as well...typically several pressure ulcers each, usually sacrum/coccyx. So, most times they poop dressings must also be changed.....pts are typically dead weight and cannot even hold on to the hand rail to help......

mindlor · Aug 22, 2012

LilgirlRN said:

There are several different things that an RN and a CNA could both do on the CNA level but hardly anything that can be done by a CNA on a nursing level. You only have 15 shifts under your belt.... you gotta learn to delegate. I don't believe in sitting on my butt if there's nothing that needs to be done on the RN level. I can clean poop with the best of them. The shift you described however shows that your patients had very high acuities. The RN stuff needs to be your first priority! If you have trouble approaching the CNA's in terms of delegation, I would just tell them the truth. You can't do it all, the PATIENT needs their help. Half a$$ anything will get you in trouble these days. I'm gonna assume that you're not the charge nurse. Ask her/his for help. Make sure your manager knows of any problems cause if patients/families start complainingyou may be able to head 'em off the pass so to speak.

There is no one to delegate to. There is only me, myself, and I. At my facility primary nursing means I do it all, no help

Esme12, ASN, BSN, RN · Aug 22, 2012

RN In FL said:

Oh my, I totally stand corrected. I BEG YOUR PARDON.

:lol2: too funny. It does sound no nonsense doesn't it? I had a good friend become the DON of an LTAC....she needed a supervisor and I needed some cash....after all how hard can this be? A nursing home with a couple of vents.......Right?

MAN WAS I WRONG!! Those people are sick! The LTAC I supervised has an ICU. These were fresh post open hearts that had complicated post op courses and failure to wean. They came with PA lines/Swans, drips and arterial line intubated on the vent. Halo tractions, open chest wounds on the floor with vents and dialysis...unbelievable. These are tough places to work A new nurse will learn a ton but they work their buns off

Take a peek at the new forum for LTAC/LTACHS Long Term Acute Care (LTAC/LTACH)

anotherone, BSN, RN · Aug 22, 2012

Seems more like ltachs like that one is for the birds. Some places like to advertise all RNs but fail to report what that really means. CAnt believe how many posters don't have a clue. I do not care about doing " cna work" or any other nonsence. It is the easiest part of nursing to me! The reason it sucks is because (i work med surg) when we dont have aides there is not anyone to help. the other rns/lpns are busy. Had a complete care covered in poop . I can not turn 250lbs by myself nor will i try it. Pt had to wait 30mins for another rn to be free to help. already had some skin breakdown prior to this. PRIMARY care is okay for when we have mostly walkkie talkies which is rare in med surg and a NEVER in ltachs. sometimes we get pts with literally 1 hr dressing treatments. these pts can not hold themselves up. i doubt any ltach pt can. so then good luck finding an rn free to help for an hr!!!!!! ugh. all this to save the $9/hr cnas get where I work.

Good Morning, Gil · Aug 22, 2012

Our ICU is primary nursing, too, Mindlor. And, that can be difficult even with just 2 patients sometimes if they're pooping every 2 hours lol, and it's not liquidy enough yet for a rectal tube, for instance. A super critical patient and a detoxer together, for instance, can be challenging. I think that's why ICU's have a higher turn-over, as well; it's back-breaking, especially since many patients are obese, and many patients are working against you (detoxing, drug abuse, psych, or just the ICU delirium).

Good Morning, Gil · Aug 22, 2012

Oh, and Mindlor, here's my philosophy on rectal tubes: if someone is vented, not very alert, a rectal tube is a good option to manage frequent diarrhea (3 or more loose stools in 12 hours qualifies in my opinion). This will help prevent skin breakdown, as well, especially if they already have decubitis. Obviously, get the order first, but they are good for both the patient and the nurse.

Just be sure to flush/irrigate them with 200-300 ml of water through the irrigation port to keep them from leaking; if you don't do this once a shift, they will leak.

HouTx, BSN, MSN, EdD · Aug 22, 2012

Sorry to nitpik, but if I get the gist of this thread, PPs are talking about Total Care rather than Primary nursing. With Primary nursing, each patient has a primary nurse who is responsible for establishing the plan of care & coordinating all the 'stuff' concerned with the entire stay.. case management, discharge planning, teaching plan, etc. His/her name is in the chart - just like the admitting physician - and every primary nurse has a patient load. But Total Care means that the assigned RN has to do it all with no assistance for that shift. Total care is the normal care delivery model in most ICU settings.

I think that Total Care outside an ICU setting is complete bunk. I am a huge proponent of team nursing. In today's world of shrinking reimbursement, we have to provide more care with less $. There are only 2 ways to do this. 1) all of us take pay cuts and never get raises again or 2) use a differentiated care model whereby higher-paid staff can be stretched farther by limiting their workload to tasks/activities for which they alone are qualified & they supervise others who perform all the other work. I vote #2, what about you?