Unit care models, team nursing, input please!

[LEA1]

I work a med-surg unit (urology/nephrology focus) in a hospital that serves a large rural region. Our unit census is 40 patients at capacity. On day shift we usually have 5 patients per RN which I feel is a reasonable NUMBER...however acuity of the patient is not really factored into our daily assignments so the managability of this load can fluctuate greatly day to day. Our aides are typically covering 12 patients which I feel is too many as a high percentage of our patients are diabetics, elderly and bariatric, requiring two assists to do just about anything.

We have been experiencing a lot of change in last several weeks as we prepare to go live with a new 100% computerized med administration system. Our procedures for entering and signing off new orders have changed, we're in a state of indescision over where to keep the paper patient charts (we use 100% computerized flow-sheet documentation). The role of the charge nurse is also in a flux as she is no-longer signing off orders and they are considering giving charge a patient assignment. In addition, the patient acuity has increased (more post-ops, isolation, telemetry and wound/tube patients) and the bed turn-over rate has risen.

The last two weeks the entire floor has been over-time on all shifts on a daily basis and the quality of patient care has dropped terribly. We continually have a high nurse aide turn-over rate and are often working with float pool aides or new hires who just don't have the flow of the floor down yet. Many of us are at our wits end and after discussion with management it was suggested we try a team nursing approach to see if this can help our situation. Because we already have autonomy over how we divide our assignments within the unit and this reflects 0 change in budget it's something we are able to try instantly. I'm one RN on the guinea-pig team that starts trialing the care model tomorrow.

We will be pairing two RNs to cover 10 patients (same nurse to patient ratio) with our own aide (aide load will be reduced by 2 patients). The idea is to divide the labor; one nurse begins the med pass while the other does the assessments. This model was used a lot back in the 80's though usually with 1 RN and 1 LPN and an aide.

The aspect of this approach I am excited about is that I should be able to coordinate with my aide better for all those total care / 2 assist patients. I waste considerable time looking up and down the hall for help with the current system, many of us get frustrated and try to reposition alone and end up with injuries etc. When I help my aide with those total care baths, I get to do a through assessment at the same time. The aide gets her morning care done faster and can then help with the q2 hour turns, ambulations etc.

Another aspect I like is that as a new grad, I will be teamed with an experienced nurse. I value the availability of a mentor when I come across a new or difficult situation.

A common concern for this approach is your dependance on your team-mate. You have to be able to trust the nurse you are paired with, both remain responsible for those assessments and meds for all 10 patients. We've gotten so ingrained in the cover-your-hiney mentality its hard to put so much trust in a co-worker. You have to have good communication skills as well....some of us on the floor really need help with that.

Another concern I hear is that if you divide the tasks instead of the patients you only get half the picture of twice as many patients. I can see that point, however with the high-turn over and patient acuity I'm dealing with now, I don't have time to review patient histories or keep up with their labs and read physician progress notes, and then before I know it they're discharged or transferred to rehab. I'm not getting the whole picture as is. The Team Nursing model I saw demonstrated in school was in the long-term care setting, it seems this care model fell out of favor in the acute care setting years ago and I'd like to learn more about why that may have been. If you have worked with the team nursing model before please give me your feedback. What did you like, what did you hate? Any suggestions for how to divide the work? Have any links to articles on the topic or have a different care delivery model that you recommend? Please please please help!

[cmo421]

Wow,long post. I have to tell u I just skimmed it,but I think I got the idea. When I first started in nursing we did team. On nights,it was hard because then u had a poor ratio,so u did what u had to do.(if we had 4 nurses,we did sides,if 3 we all went along room to room) When I went to days,it was great. The 42 pt floor was divided up into 4 teams or modules. Each one had a RN,LPN,NA. The LPN and aide did vitals and a quick look right away while the RN got report and dealt with any immediate needs.The RN then gave her team a report. Then the Rn started meds and did assessments and she went along. The LPN and aide started care and the RN assisted when they were done with meds and as she went along. You really counted on ur mates to bring things to your attention and you really all depended on each other. Now as always some worked well,some did not. But all in all,it really worked out fine. If some from other mods where finished early, they would help . In emergencies and such, we just all pulled together. Back then the pt's and paper work were different. Most of it,besides charting,could be shared. Acuity now is higher,and paper work is immense. I still think it could work,especially if everyone really wanted it too. Team working really makes everyone feel accountable and valuable. After all,all levels of nursing is needed to get through the day!

[kstec, LPN]

I second that cmo421. All levels are needed and should be utilized.

[RN1989]

I do not care for team nursing. When you are passing meds, you need to have assessed that pt. That pt may need a dose of prn lasix but if you have not checked lung sounds or leg edema, you may be unaware of this. And if another nurse came and told me that I needed to give lasix because of these issues - I myself would still have to assess the pt before I gave the med. And as you said - you have to trust the other person. It is very difficult to find someone that you are compatible with. There are very few nurses anymore that I would trust to do an accurate assessment while I did meds and there are very few nurses that I would trust to give meds on my patients without screwing up. If I am to be responsible for the patients, I want to be responsible for them and not have to pray that my partner is able to use their brains and is willing to actually get off their butt to do the job. Working with an aide is fine - no med issues/assessments issues etc. But I have yet to see where team nursing actually works. When hospitals are trying to save money they always think that the old team nursing is the way to go. Perhaps 50 years ago when nurses were little more than glorified maids, team nursing worked. After all, I've heard all the stories about a 50 bed unit being staffed with only an LPN and an aide on the night shift. But now, with our litigous society and my license on the line on a daily basis due to hospital understaffing - no way do I want someone else in the mix. If I'm gonna make a mistake, I want to do it on my own without having to watch my back and get blamed for what a team nurse partner does or doesn't do or fails to tell me or the doc. Communication is even more important with team nursing and it usually breaks down because you both become so busy that you don't even see each other for most of the shift. Or the reverse - you can't get anything done because you keep having to have pow-wows to tell each other what you've done/haven't done etc. And then it is irritating to walk in and not know what the other person has told the patient, or the patient says "But the other nurse said I didn't have to get oob for my meal". Very easy for manipulative patients to play the nurses against each other.

With what your place is suggesting - if you are all RNs, I say you split the load evenly and share the aide. You become each other's designated backup for any lift assist, lunch break cover, etc. Much safer all around and then you never have to wonder who you can get to help you.

[cmo421]

Nursing is like the spinal column, the ones on the botton carry alot of weight and support the higher ups!. I found I could do assessments as I pasted my meds. I did the early meds(insulin,etc,,,,) first and then the rest as I went. It worked for me and Trust is something u have to be open to and people earn.

[farnsel]

I work on a 35 bed med surg unit we either have a team of 8-9 pts on a team ( RN and LPN) or 4-5 pts on a primary. we have only 2 aides for the entire floor and sometimes only 1. With such a high turn over rate of pts each day the charting on admissions and discharges are overwhelming for the Rn espcially on the team. We all have to give baths and do treatments. Now we are trying to get magnet status I don't really see how that is going to aid in pt care which should be of most importance. They just told all are LPN they have to become Rn's within 6 years or they are out of a job. The majority of these nurses are between 42 and 55 years old, they are devistated. I've been a nurse for 30 years and still see the importance of good Lpn on a busy med surg floor. Any comments