Total care nursing

Jolie, BSN · Jan 19, 2007

Practiced in its purest form, I believe that total care (or primary) nursing is the ideal method of patient care. The RN assigned to the patient provides every aspect of nursing care, including care planning, assessment, carrying out hands-on care, providing medications and treatments, collaborating with other team members such as physicians, therapists, social workers, and pharmacists, and communicating with family. The RN becomes the ultimate "expert" on the patient's status and needs and is well-positioned to take a leadership role in the patient's care.

For this model to work, nurse-to-patient ratios must be kept within reason. I am no expert on med-surg, but I would venture a guess that 4 med-surg patients would be the max for this model of care. There must also be tremendous teamwork, with RNs working together to provide physical care to patients who are obese, immobile, suffer dementia, or have complex physical needs. These two factors (staffing and cooperation) are unfortunately often over-looked by hospital administrators looking to cut costs. When CNAs and LPNs are not available to assist with certain duties, the number of RNs must increase. Often the bean counters simply eliminate the CNA and LPN positions without making satisfactory adjustments in RN staffing. And on a unit where the nursing staff is not cooperative and cohesive, this model of practice simply will not work.

I once worked in a hospital with an old fashioned L&D, post-partum, and newborn nursery set-up. Each of the 3 units was entirely separate with different staff, management, policies, and procedures. There was very little cooperation or communication between the 3 units. When a mother delivered, she was promptly transferred to the post-partum unit, and her baby sent to the nursery. Neither receiving unit received much of a report, so important information (like pregnancy and labor complications) was often not communicated to the PP and/or NSY staff. PP and NSY were likewise poor about sharing information with each other. There were situations where mothers were treated for post-partum infections that the nursery staff knew nothing about, and babies who were admitted to the special care nursery without the post-partum staff being made aware. As you can imagine, patient satisfaction was not good, and neither was the quality of patient care.

On that particular post-partum unit, a new mother could encounter as many as 7 staff members during the course of a single shift: the RN who did her assessments and managed her IV, the LPN who passed meds, the CNA who took vitals and passed linens, the bath tech who assisted post-operative moms with bed baths or showers, the dietary aide who passed trays, the nursery nurse who cared for her newborn, and the breastfeeding nurse who made rounds on nursing mothers. Each staff member knew a little about the patient, but no-one had a comprehensive picture of how she was doing. It is no wonder that important information fell thru the cracks and went unnoticed until a crisis arose. This unit could have served as a "poster presentation" on the value of primary nursing!

Pepper The Cat, BSN, RN · Jan 19, 2007

We practise total care - all RN or RPN staff. I wouldn't work any other way!

I know everything that is going on for my patient. And I mean everything!

We had one unit where they used PSWs (personal support workers) for bedside care. The pts our unit rec'd from that unit always came down with problems that were missed - no BMS for days, bedsores that weren't care for etc. I think pts get better care when there is only 1 person responsible for them for the shift.