Shifts

[AMMLPN]

I am new to the hospital setting. We have a NEW team nursing model. The way this is supposed to work is that the hall of 18 patient is split down the middle. This gives 9 patients 1 RN, 1 LPN, and 1 CNA.

I am very interested to know how this works in other places since this is the first place I have done it and it is new here as well.

What does your normal shift look like? How are the roles divided? How do you make sure everyone is on the same page? Who reviews the chart and when is the best time? Do you do that before you see your patient? Before report doesn't seem like it would work here at all even though I think it would be optimal. However, a lot of times I don't even know who I have until I am handed papers and going to report.

I would like to bring some new ideas to my boss, but I don't really know where to begin. Please, my more experienced nurses, please tell me what you do on a typical night or day and how it works for you. I know everything changes and sometimes nothing goes as planned, but if it did, what does it look like?

Thanks a ton in advance.

[peripateticRN, BSN, RN]

This is the type of nursing we have at the hospital I work at - although we typically have 3 teams per unit of 32-36 patients (but same jist).

Anyway.. what is SUPPOSED to happen is at the beginning of shift the entire pt load is examined and the RN will assign who has whom (between the RN and LPN) to get a roughly equal load. Because there are competencies LPNs are not allowed to do (ie spike blood, hang TPN etc) the RN SHOULD take these patients. In our hospital, initial patient assessments are done together so all team members are familiar with the entire assignment and can answer questions and have some idea what's going on when the other nurse is on break and so on. In this model the RN is ultimately responsible for the entire team and generally, the RN does chart checks, lab checks and makes the calls to the MD (this is why we make the big bucks I guess). In this model there is no designated charge nurse. We have a resource nurse that signs timesheets etc but no one who does not have a full pt load of their own that can follow up on labs and so on.

Now.. Reality. Usually in the team of 10 or 12 patients, assignment is transferred from the last shift - ie the RN takes the previous RN's beds and the LPN takes the LPN's beds. This sounds great until you've had a lot of movement and 'bed 2' now has blood, tube feeds and a trach on high flow (and is assigned to an LPN who cannot legally perform half the care needed). Now the RN has their own 5 pts and is spending huge amounts of time with the LPNs pt. If everyone is on the ball - then that message should be passed to the next shift so they will rearrange their bed assignment.

There have been a lot of concerns I have seen with LPNs complaining that they have a heavier patient load than the RN (sometimes justified... sometimes not).

I have been a float for the last year - and have found that some units expect the RN to be the point person for all calls to the MD, Chart checks and labs, while other units the lpn takes care of these tasks for their own patients. While I understand the as the RN we are meant to be the leader of the team, I find it really hard to keep track of all aspects 12 acute patients while still providing adequate care on the floor. This is my major concern with this model.

In terms of timing - I usually come in 15 minutes before shift - find out what my assignment is (usually by flagging down the current shift and finding out what beds the RN has.) I print out my med sheet, grab a kardex and start making notes. Preferably report is done bedside/in the hallway for your team of patients only (some units still do the whole unit report which I feel is a waste of 30 minutes.)... then the RN and LPN get going on assessments. if your HCA is awesome they will work ahead and start doing vitals or answering call bells.

On day shift charts get checked after MDs rounds, at night they get checked usually in the dark of night once things have calmed down. Sadly when things are hairy chart checks are usually the first thing that gets dropped. One of the problems I have with this system is that it is easy for hours to pass before getting around to the charts - without having someone that is stationary that new orders come through it can be hard sometimes.

I'm not sure if that answers any of your questions.. let me know if you want to know more.

[AMMLPN]

It answers quite a few. See, the way it is now, the RN and LPN don't split the 9 patients. The RN does the assessment and the LPN gives the meds. The RN does most of the charting but the LPN will call the doc just as easily on all 9.... It all seems a bit messy but I think that's because it's all still so new.

[peripateticRN, BSN, RN]

It answers quite a few. See, the way it is now, the RN and LPN don't split the 9 patients. The RN does the assessment and the LPN gives the meds. The RN does most of the charting but the LPN will call the doc just as easily on all 9.... It all seems a bit messy but I think that's because it's all still so new.

Interesting - I remember talking about this style of team nursing in school, and being told most places have moved away from it for one reason or another (but can't remember the details)

I feel like it could work really well as long as communication was on pointe on your team. On the downside I would hate to have to do the med pass for all 9 patients - but perhaps that's just me. :-)

I feel like this way definitely has clearer RN vs LPN lines though - even if you say the LPN will call the doc themselves as well.

[mrf0609]

I first became an LPN prior to my RN and worked in a hospital as a team. The RN did all assessments and called the MD for orders, since the LPN could not take orders, which I am not sure why... As the LPN I did all med passes, dressing changes and did most hands on care. We had CNAs, but they did the bare minimum and it was allowed. We typically had 8-12 patients. The RN would hang blood and give IV narcotics, some would do more, but most sat at the computer and charted all day. To this day I still get frustrated thinking about the RNs who would not assess wounds, how do you chart on them??? The LPN did have charting, but I primarily wrote a lot of notes. When they phased out LPNs we were told that patient outcomes were better with RN as primary care givers. I think cost is a factor when establishments use team nursing.

[AMMLPN]

I think when bringing us on they said it was a staffing factor. We simply don't have any can't keep enough RNs on the floor at any given time.