Primary Nursing and Night shift

[queenjean]

Does your facility practice "primary nursing"?

By primary nursing, I mean where each pt is assigned a primary nurse. That nurse has overall responsibility for each pt--oversees the care plan, communicates with physicians and other staff, etc. When the primary nurse isn't there, "associate nurses" (ie whomever is available that day or night) take the pt. But whenever the primary is there, she/he takes that pt.

Our facility has gone to this (though we were kind of doing it before since a lot of it is simply continuity of care and common sense), and we have an issue as night shifters. I don't want to start a day shift vs night shift kind of thing, but here's the deal: we night shifters feel like we cannot be primary nurses.

Here are some of our reasons:

1. We have no active collaboration with any other staff except for respiratory therapy. I have never even seen a PT or OT; I rarely am able to speak with the pt's physician (just whomever is on call, and then only for acute matters at 3am). I can't identify any social worker by name or sight, I don't think I've ever seen any of them. How am I supposed to coordinate care and collaborate with other fields when I never see any of them? Care conferences only take place on days. As a night shift primary nurse, I will never ever participate in a care conference. Neither will I ever attend any meeting between family and social work, the primary physician, hospice, pain team, wound healing team, or palliative care team. All those meetings occur on days.

2. We have little collaboration with family. Maybe we see them for an hour or two. Visiting hours end two hours after my shift starts. How am I supposed to be a "go between" between the family, pt and the other disciplines (including the primary and consulting physicians) if I only have two hours (the busiest two hours of my shift) to even have the potential to see or talk to the family?

3. As primary nurses, at some point during my shift I am supposed to sit down with the pt (and family if possible, especially if the pt is not a/o x3) and discuss the plan of care. I start getting report at 1900. Assessments are due by 2100. All hs meds and care are to be completed by 2200. When am I supposed to do this? 3am? Should I wake up my pts to do this? How about call their family members/DPOMAs to ask for their input? Of course this doesn't work. I rarely am able to do this on nights. By the time I've finished with my more pressing tasks, visiting hours are over, pts are ready to go to slee, and family members do not want phone calls unless the pt's status has changed. Yet we have been told in no uncertain terms that this care plan discussion is an "expectation". Really? But of course no true guidance on how to actually do this.

4. Manthey, who "wrote the book" on Primary Nursing (the one that our managers requested we read, and the book upon which we are basing our primary nursing practice) states that as a rule night shift should not be assigned as primary nurses, mainly for the reasons I have stated above.

So, before my fellow night shifters and I go to our administrators with our concerns and suggestions (basically that day shift be primary nurses, night shift be only associate nurses and maybe try to assume some of the administrative, paperwork heavy tasks of day shift to free them up to do more of the primary nursing stuff), we wanted to know how other facilities with this form of primary nursing in place handles this.

Are night shifters primary nurses where you work? If so, how do you handle the collaboration with other disciplines? What about care conferences?

If not, what tasks and duties have night shift assumed to help free up some day shift time? We don't want to just dump this all on day shift without helping them out in some way. We already do all the MAR checks and stuff the charts. What other tasks could we do to free up their time?

Thanks in advance for the input!

Jean

[snuggles49]

We do "Primary Nursing" if you interpret that to mean "a nurse cares for 5-7 patients and is responsible for all meds (LPN have resource RN for IV pushes), ADL's(can be delegated to CNA), documentation (includes careplan, full assessment, nurses notes, pt teaching, I/O, VS when their is no aide), noting orders, calling doc's (plus calling for LPN if you are resource), dressing changes, set up for procedures (central lines, chest tubes, etc. The noc shift does the same as the day shift. RT an PT work with the patients and are available to discuss patient if needed. Our noc shift does the verification of the MAR for the following day. Why do you have to be the go between family members and the doc/other disciplines ? If the patient can't speak for themselves or unable to then family members need to be there when docs make rounds or find another way to communicate with the doc. As for discussing the careplan with the pt most likely the dayshift has already and just needs noc shift to reenforce the plan. Simple you talk about pt goals and interventions while your doing pt assessment. EX: Mr. ? the goal tonite is to have you walk to the door and back as this will help get your bowels functioning after your surgery today and prevent complications. Primary care is not difficult. Most nurses like the control they have over their pt care, they get to know the patient well esp. if working a 3 day stretch (we are 12 hr employees). By the way what are the responsibility of an associate nurse Good luck in your transistion I think eventually you will like it.

[queenjean]

I understand what you are saying. We have always practiced a continuity of care and have never done team nursing. I have never had an LPN pass my meds, for example. I sometimes have an aide, but usually I am responsible for 100% of my pt's care.

As a primary nurse as our facility requires it, each pt is assigned ONE primary nurse. The primary nurse is responsible for initiating the care plan and overseeing the care. He/she is responsible for collaborating with other disciplines to ensure the pt is getting all the appropriate care he/she needs. We are to think of ourselves as somewhat independent practitioners--similar to a physical therapist. We are collaborating in the care on equal footing with the other disciplines. The associate nurse is the nurse who is taking care of the pt when the primary nurse is not working. So on the shifts that I don't work (all day shifts and any of my nights off) the "associate nurse" takes care of the pt. Does that make sense?

As a night shifter, it is difficult to fulfill this role.

[Ruby Vee, BSN]

my experience with primary nursing was somewhat different than yours. not every patient had a primary nurse -- the ones that came through for surgery and would be transferred out of our icu in a day or two didn't get one. but anyone who was in our unit long term (and those were the days when cardiomyopathy patients would stay in the icu for over a year, on and off balloon pumps and waiting for a transplant) would get primary nurses. (yes, sometimes more than one.) in some cases the nurses would self-select, and in others management selected.

i was on permanent nights in those days, and was still able to serve as a primary nurse. a few times, i stayed late in the mornings to attend family conferences or to interface with ot or pt; other times i discussed my concerns with the day nurse who would be caring for the patient that day and he or she served as my representative for the family conference. some especially long term patients had several associate nurses in addition to the primary nurse, and we'd discuss the patient at change of shift, and pass on concerns to be brought up during the day. i found that the physicians were still available at night, although not for formal rounds. but i was still able to discuss my patient with them when they showed up for other things, and sometimes they'd look to see which primary nurses for their patients were around at night and check in with us before they went home.

for the most part, i found primary nursing to be very rewarding. there were those obnoxious patients that everyone hated to get stuck with, but if you got stuck with one of them for awhile you got a break the next time an obnoxious patient needed a primary. unless of course, you wanted to volunteer. a few of my favorite patients were the ones other nurses considered so obnoxious they didn't want to take care of them!