By Rose O. Sherman, EdD, RN, NEA-BC, FAAN
Few nurse leaders are saying this aloud, but most realize that it will be impossible to deliver primary nursing care in the future. Assigning nurses to 8-10 acutely ill patients (happening in many settings) and describing it as primary nursing is incompatible with that delivery model.
Primary nursing replaced a team nursing approach that evolved in the post-World War Two era when there was a shortage of nurses and an excess of support staff trained as part of the wartime effort. In a primary nursing model, RNs accepted responsibility for administering and coordinating all aspects of the patient’s nursing care, with the support of other nursing staff members. The goal was to promote continuity of care across the length of stay, with nurses having greater insight into the patient’s medical and emotional condition. To deliver care effectively, nurse-patient ratios needed to be relatively low.
If we look at where we are today, it is clear that this model is not sustainable moving forward outside some clinical areas (ICU, OB, OR). We don’t have enough nurses ready, willing, and able to bring acute care ratios down to a level where primary nursing can be practiced. When I mentioned this idea recently to a group of leaders, they asked me about the problem of continuity of care with a team model.
My response is that we are kidding ourselves if we think we have continuity of care in most settings today. The implementation of 12-hour tours, the addition of travel nurses, and the shift to part-time work have led to challenges in promoting the continuity of care that were the cornerstone of the primary care model. We also have a nursing workforce whose career goals have shifted away from direct patient care in acute settings.
Nurse staffing is critical in many medical centers – the leaders know it, and the staff know it. In an interview, one manager recently told me that his unit is about five resignations/retirements away from lapsing into chaos. What is happening in our hospitals today is not sustainable and certainly not a recipe for quality and safety. The only way to move forward is to optimize the role of the RN.
A good starting point is to study what nurses are currently doing in our health systems and seriously ask whether all these tasks/activities require the expertise of an RN. Melinda Stibal, a CNO in the Legacy health system, recently shared on a webinar that research in her facility indicates that 48% of things nurses do today don’t require a nursing license. As an outcome of their findings, they are redesigning care. Most nurse leaders know that they need to do this. Sometimes they don’t know how to begin, and few want to be the first to implement significant changes in a time of increasing unionization.
A good starting point is to have the leadership team discuss the following questions:
1. If we were part of a brand new system that had the opportunity to design entirely different care delivery, what would we do differently?
2. What parts of our care could we eliminate or reduce and lose very little value to the patient?
3. What are the most time-consuming activities for RNs that others could do?
4. What is the availability of support staff in our community?
5. Can we look beyond traditional healthcare team members to support inpatient care?
6. What needs to happen to change the current RN mindset and upskill our RN workforce in supervision and delegation skills?
7. What are our problem-prone units that might be a good fit for a pilot project?
8. Who should be on the care delivery redesign team, so we don’t overlook critical stakeholders?
None of these changes will be easy, especially with the severe labor shortages and high turnover among Certified Nursing Assistants and Patient Care Technicians. Some health systems are already looking outside traditional healthcare roles to support teams, such as using exercise science majors and in-house grow-your-own programs. Changing our delivery model may mean sacrificing some sacred cows. It can also be incremental with small pilots on units that are already very problematic to staff. The current health care environment is challenging the sense of order for many nurses with long professional careers. When we feel fearful, it can be comforting to cling to what we know has worked in the past, but we can’t do this moving into the future.
© emergingrnleader.com 2022
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