Teamwork...in an Imperfect World.

Anna Flaxis, BSN, RN

I recently took a new job where I was just amazed by the teamwork displayed by the entire staff. I was just in awe. But now, the honeymoon is over. I'm starting to see the chinks in the armor. Like Neo in "The Matrix", catching glimpses of the true reality, I am beginning to "wake up".

Don't get me wrong- the teamwork really is outstanding. Nobody ever utters the words "That's not my patient.", or when a physician asks who is taking care of Patient X, we might respond "Joe has been, but what can I help you with?". If there are orders to be transcribed, IVs to be started, meds to be given, EKG/Radiology/CT techs to be paged, whoever is not doing something at the moment just does it. Well, mostly.....

I work with one particular nurse who has....habits, shall we say...that I struggle with. It has made me see the value of zone nursing, where each nurse is assigned a set of rooms, or primary nursing, where each nurse has a set of patients, and those are their patients that they are responsible for. This is the background I come from, where I cut my teeth in ED nursing, and I have really enjoyed the team nursing approach in comparison. But, I've been seeing the value in zone or primary nursing lately.

What are these habits, you may ask?

Well, disappearing for one. Not just for a few minutes to go to the bathroom or something, but anywhere from 15 to 30 minutes, where I do not know where my partner in nursing is. I tell my partners where I'm going, even if I'm just going to the bathroom. That way they know, if something happens and they need me, where I am. Not this nurse. This nurse seems to feel it's okay to be gone without saying anything. To be fair, sometimes this nurse does tell me where they're going- for instance they will clock in and then tell me they need to go deliver a book they're lending to another nurse over in OB- and of course, they're gone for no less than 30 minutes.

Another thing is cherry picking. This is where the other nurse picks the patients they really want, sometimes even taking a patient right out from under me, and is conveniently busy when patients they don't want show up, leaving the other nurses to take them. This nurse tends to cherry pick the traumas and critically ill one on one patients, leaving the other nurses to manage the rest of the department.

Lastly, the "going the extra mile" thing. This is where the nurse will spend a good 30 to 45 minutes on the phone with a patient that was seen in our ED last week but still has some questions. This wonderful, caring nurse will spend as much time on the phone with the poor hapless soul as it takes to solve all their problems, while we're getting hammered with real patients who need real care in our ED right now.

I won't mention the personal phone calls. Oh, well I guess I just did.

So, what is my plan to address this, you may ask? Well, I considered talking to my supervisor. But this nurse has been around for a long time and has pretty close bonds with my supervisor. I don't want to have to watch my back. I was happy when I found this job and thought those days were over, and I want to maintain that illusion as long as possible.

So then I thought maybe whenever I work with this nurse, I'll just take care of my own patients and spend as much time in my patients' rooms as possible, sticking to a more primary or zone nursing model. But, this can be really inefficient, and not helpful to the patients.

Ah, I know what I must do. I must address these habits as they happen in the moment. I have to actually communicate with this other nurse about these habits. I'm not sure exactly how to do this- interpersonal communication is not my strong point, especially where conflict might be involved. It's something I work on regularly. Maybe that's what I'm supposed to gain from all of this- more practice in this area of weakness of mine. It's not really what I want. I'd rather practice difficult IV starts or hone my respiratory assessment skills.

Sometimes, however, getting outside of one's comfort zone, outside of that bubble of safety, is how we grow....and so, I will look at this as another one of those unsolicited opportunities for growth.

And maybe, just maybe, the teamwork will be enhanced as a result.

jadelpn, LPN, EMT-B · May 22, 2014

The issue I have encountered with everyone having a hand in the cookie jar is that sometimes, if not properly noted, I am noting the same orders as someone else already has, but failed to document they did so. Or making that second call to radiology. So if there's a system in place to make sure that you know when someone takes off one of your orders, then it wouldn't be so bad.

I would resign myself to the fact that the nursein question is only half working, and that when you are partnered with her, do not count on her doing much of anything. Unfortunetely that means that you have to be more on top of your game than you are already.

If she is not telling you when she is leaving the unit, then you need to be aware that she is mostly off the unit, and when she shows, task her in a nice way. I am not sure how she can take an assignment and then not be available to care for the patient! That shows in documentation I hope. If it causes no immediate harm to the patient, I would let her sink or swim. If she is taking advantage of the fact that others are going to pick up her slack and do her work, either don't do it, or do it all and document same. When she returns simply tell her (and hopefully within ear shot of the charge nurse) "you were unavailable so I had to take over care of your patient, as there were multiple orders". No drama, no accusing, just factual.

Cherry picking is not necessarily allowed if nurses are assigned rooms as opposed to patients. And if their rooms are unoccupied, then perhaps they would be available to help with other busier nurses. Just cover yourself, always. And be sure that if you do not put in orders or make calls yourself that you double check it was actually done.

Great article!

ProgressiveActivist, BSN, RN · May 22, 2014

It sounds very political. Tread carefully. It is probably best if you prove yourself and foster good relationships with everyone before you tackle the issues with ms. Supernurse.

amygarside · May 22, 2014

Strive to become a good example to others. Just don't let them abuse you. If you are a good leader, you can do this. Best of luck.

ProgressiveActivist, BSN, RN · May 27, 2014

One approach that has worked for me in the past is to speak to the person privately. Do not say a single word to anyone else. Say I wanted to warn you that people are starting to talk about how

you aren't available when we need you. They also say you don't take a full assignment. So she is on notice that her coworkers are on to her and are getting fed up. This is very effective in dealing

with people who have an inflated ego.

or how about just saying: hey Sally did

you know you have a pt in room 5? Or if you get a critical pt say : thanks Sally I got this. Last time I checked I was assigned to this room. ER nurses aren't exactly shrinking violets so I guess it comes down to picking your battles.

slevine12 · May 28, 2014

Wow I haven't even started Rn school yet but as I read the boards I'm finding some very immature and lazy behavior on some nurses part which astounds me. It sounds like she has been there for awhile and just feels like she doesn't have to pull her full weight anymore ;(

movingon2014 · May 28, 2014

You have to like where you are at, or you will burn out. A large part of that, is liking your colleagues. If there is only one bad apple and you truly like the other staff members, then join together with them. EVERYONE needs to speak up to this person, EACH TIME she is caught goofing off. If she continues to do this, then it is time for everyone to go to the supervisor as a group. If she really does not care about her patients, think of the next possible scenario ------- the unit is so busy that one of her neglected patients is harmed by her neglect. Act now before that happens. And if there is no one else on the unit who thinks it is a problem, or refuses to join together, then is the the "team" that you really want to stay with? -- Better to move on than to burn out.

lumbarpain, ADN, RN · May 28, 2014

I moved to a southern state...I was out of my element...I felt that people where I lived had this "THING" against me cause I came from up North....through time and starting a new full time job in Long Term /REhaB I found this facility to be BEYOND disorganization...BEYOND Incredible verbal abuse toward patients and BEYOND the staff having their own ways to do things....and the DON expecting NEw comers to straighten things out...I found this terrible......she offered no help or comments in regard to THOSE nurses and aides...just LEAVING THE FLOOR without letting any one know....I have worked with 2 nurses whom have taken severe advantage of prolonging their breaks....saying they are going upstairs to help with an admission and SMOKE BREAKS...MY GOD....this state is terrible with smoking....anyway.....I have found myself ALONE for almost 2 or more hours total with 50 patients.....I am at the end of my rope.....and I am going to write a letter to the DON about this....I didn't name names...but I suggested that she put with with other nurses WHO don't leave the unit like these other two...I know the DON is having much difficulty getting another full time nurse to work on my unit because of the STAFF that just do what they want.....and the Nurse cannot tolerate this behavior...but I have been there over 4 months...I am tired of it and have never in all my years of nursing seen any facility as bad as this one with organization and disciplining their employees......This is what I am so afraid of with this Obama care nation coming into being.....it going to make people very lazy and all the ones who NEED TO HELP PEOPLE will be taxed and overburdened and they wont care......there are the good considerate caring people and the ones who want everything done for them.....this is what I worry about in todays world. Hope it never comes into fruition and people turn to help each other more and more each day instead of expecting or depending on the ONE WHO Always does it all the time.

ProgressiveActivist, BSN, RN · May 28, 2014

To lumbar pain:

I would hand the family members the number and website for the CMS and say please report this.

el10john · May 29, 2014

Just remember, when planning on such a confrontation, do not wait until you have worked up enough anger-induced energy and determination. Your anger will come across as hostility and threatingly. This will only make it FAR worse. Cut back on the coffee prior to talking to her :-). One other thing, make sure you can look her in the eyes. If you can and be steady doing so, you are ready to talk! Good luck!

Grace404 · May 29, 2014

Wow! Sounds as if we may work in the same ER. I am all for teamwork. Having come from a "zone" environment, the total team concept has been difficult for me to completely commit to. At times I feel, the "team", up to 5 plus at times, will converge into a patient room, perform necessary tasks, than go onto the next room. Now there are definitely appropriate times for this to occur, however; this leaves the patient feeling overwhelmed, and terrified. The tasks completed, the time on the board looks great, but in all the mechanics of timely nursing, the patient was never given an explanation. I've been asked by patients if they are okay, as they don't understand why so many staff members were required to care for them at once. I've heard patient's refer to the staff as 'machine-like'. Understanding we all are busy, I believe as a nurse we are responsible to keep the human aspect alive in our practice. Not to mention, having team members complete ordered tasks, without charting. I feel I lose control over my patients care, and feel unprofessional when a patient tells me, "oh another nurse just did that" this type of help wastes time, and is frustrating. Add in the disappearing team member, seemingly always gone when a Doc is inquiring information pertinent to a patients care, I wonder, just how do our patient's perceive our great team work? I feel blessed to have learned from some phenomenal nurses back in the day when we were assigned 4 patients, yet helped each other out. Don't get me wrong, there are many phenomenal nurses I'm blessed to work with today. Many, which are cracking under the stress of being the nurse they envision themselves as, being a great 'team player' per policy/procedures, maintaining accuracy at a speed we're told by administration we should have no problem handling, ensure we are meeting all the JACHO etc. requirements, oh and don't forget to fluff the patients pillow...what?? I feel the medical field in general has become mechanical, and cold in nature. I understand the politics involved, I just don't like it! Okay, thanks for allowing me to rant!

Anna Flaxis, BSN, RN · Jun 3, 2014

Lest my original post appear to be just a rant about a specific co-worker and not really an article about teamwork at all, I just want to say that even though I zeroed in on specific problem behaviors from one specific co-worker, the big picture context is that of how to promote better teamwork. In my experience, one person can bring teamwork to a screeching halt- it's like that saying, that a chain is only as strong as its weakest link.

So yes, I realize that my post may have come off as rant-y, but I ask the reader to put the specifics in the context of the bigger picture.

I think the poster who suggested leading by example hit the nail on the head. I think in this situation, where I am the newcomer and the person with the problem behaviors is well entrenched, direct confrontation may be counterproductive, and that the best way to perpetuate the great teamwork that made such an impression on me at the beginning, is to continue to behave as if that is the case and to set a good example by walking my talk.

Thoughts?

Teamwork...in an Imperfect World.

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