Many people view “primary nursing” as a negative thing.
Primary nursing for those that don’t know is when a hospital functions with
registered nurses (RNs) only. Meaning, no licensed vocational nurses (LVNs) or
certified nursing assistants (CNAs). The patient ratio is the same (at least
for California). The nurse can have up to 5 patients on a med surg floor and up
to 2 in ICU. The work to be completed for all the patients is the RN’s SOLE
responsibility. The RN is held accountable for everything.
The majority of hospitals function under a “team nursing”
model. Where the RN is the lead and is paired with a CNA and an LVN. The
patient care for 4 to 5 patients is split between the RN, LVN, and CNA. An
example of this type of nursing would look something like this:
Suppose the RN is assigned 4 patients. The CNA in total is
assigned 8/9 patients and is split between two RN assignments. The CNA is in
charge of bed baths, bathroom needs, changing linen, refilling water, emptying
drains, recording drain outputs, and helping patients with meals ect. The LVN
is assigned to 2 of the 4 patients of each RN totally 4 patients for his/her
own. The LVN can do everything the RN can do with the exception of passing IV
medications, verifying drips such as insulin and amiodarone, transfusing blood,
and verifying new orders. That leaves the RN with doing patient assessments,
contacting the MD for orders, passing medications to the other 2 patients not
cared for by the LVN and only passing IV meds for the 2 patients the LVN is taking
care of IF there is any IV
medications to give and most patients don’t have drips or blood transfusions
regularly on the floor. Essentially the RN’s main job is to basically
coordinate the care for the 4 patients throughout the day.
Before I go into my opinion on the two models of delivering
nursing care, research has proven that patient mortality and morbidity was
significantly improved in hospitals practicing with the primary nursing model.
I have had the privilege of working in institutions that
have practiced both models. I favor the primary nursing model. I favor this
model because I as the nurse am held accountable for everything that needs to
be done for the patient. I know exactly what is going on because I did it. I
know what that drain out put looked like. I know how much that drain put out
because I was the one emptying it. I know whether the patient brushed his/her
teeth because I offered it to them. I know how much water they drank because I
refilled it ect. ect.
Take an extreme situation for example such as a code. I have
an MD asking me how much fluid did this patient take in today? How much did
that drain put out the last hour? When was the last time the patient had
narcotics? I have answers right away or at the very least a really good
“guestamation” of what the answer might be. This is a very real situation. Many
MDs will be asking you these types of questions as you are cracking ribs doing
chest compressions on your pulseless non breathing patient. The MD and the code
team are going to want the RN to
paint a picture of the events leading up to the arrest.
Now, lets consider this situation in a “team nursing” model.
The patient codes and the RN is running the code but has not had the chance to
speak with the CNA or look in the computer to see if any drain outputs or urine
out put as been recorded. The RN does not know how much fluid the patient
consumed because the CNA refilled the water and fed the patient. The RN does
not know that last time this patient received narcotics because the LVN is in
charge of passing all oral medications including the norco the is ordered PRN
(as needed). Now here comes the MD as you, the RN, is doing chest compressions
and the MD starts shooting questions as you: when was the last dose of norco?
What has this patient’s urine output been so far? How much has that drain put
out? As the RN you are a deer in headlights at this moment. You don’t have any
of these answers right away because “it wasn’t your job” to do those things.
Your CNA and LVN I guarantee are not in the room either. It’s just not good.
I’ll play devils advocate because I know there will be some
people reading this and thinking: “well that’s your job as the RN is to make
sure you have all that data and you are checking to see what the CNA and LVN
are doing”. That is a very nice textbook thought but, anyone that is an RN
knows how busy it is in the real world hospital and you don’t get to sit in the
front of the computer all day tracking down what your CNA and LVN are
doing. Also, as the RN you don’t want to
micromanage your CNA and LVN constantly asking them what they are doing and
when they are going to do their next task. That is all I am going to say about
that.
This is an extreme situation but I believe it paints a very
clear picture. The RN is just not in tune with everything going on with the
patient. I find myself at the institution I am currently working at with the
team-nursing model asking myself a lot of questions about my patients because
the care is split between too many people. I then find myself chasing after the
CNA and the LVN to do their job when my phone is being blown up because they
aren’t doing their job. It creates animosity between coworkers because in a
team-nursing model it is very easy to start blaming things on others as the
reason why things did not get done. Ultimately, as the RN you are responsible
for everything that needs to be done for the patient. Blaming it on others will
not work.
I came from a primary nursing institution and I find myself
doing what is considered the CNAs job and the LVNs job all the time. Simply
because its easier for me to do it and most importantly it is in my patients
best interest to do it rather than leave my patient’s room leaving them hanging
until the CNA or the LVN can come to their aide. Believe it or not this happens
ALL the time at my current institution. Because of this thought that, “that’s
not my job, that is the CNAs job” or the LVNs job. Therefore, the RN even if
he/she has the time and is already in the patients room when tell the patient,
“ill get the CNA to come help you” and will leave and have the patient wait
another God knows how long until the CNA finally can come assist the patient
while the RN goes back to pinning posts on pinterest. It makes me crazy!
In a nutshell, that is why I am for primary nursing. What is
your opinion? Feel free to share your experiences, thoughts, or comments.
Until next time.
-Norah
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