I would like to ask for a helping hand from you.
We are about to trial a team nursing model in our emergency department and I’m not sure what to make of it.
At the moment each nurse in our ED is assigned a set of beds on commencing their shift accepting responsibility and accountability for the care delivered to the patients in those beds.
The proposed model would see a team of nurses assigned a larger *cluster* of patients that they would care for throughout the shift. In this model patients would not be assigned to individual nurses, but fall under the collective responsibility of the team.
Now, I am interested if this team model approach would in fact be best practice, or even an evidenced based approach in the Emergency Department. There seems to be a fairly evenly divided opinion in the literature although this is generally based on ward environment settings. I am interested if anyone has experience with a team based model in the emergency department setting, and if so, what the pros and cons of such a system are.
I am being asked to champion this trial, which I am more than happy to do if I believe it will improve quality of care and staff satisfaction but as of yet I am unconvinced.
Any input will be greatly appreciated, in fact I’ll shout you coffee and cake.
I have worked on an acute respiratory ward under a model of care called ‘Practice Partnerships’. I think it worked fantastically. I think that the key to effective team nursing is communication & a willingness to shift from an attitude of ‘my work’ to ‘our work’. The other part of team nursing that is really important is having escalation processes, e.g. if you have a workload that you & your partner aren’t coping with, the supernumerary team leader comes onto the floor & the nurse manager or NUM are informed to ask for assistance with workload management.
I loved team nursing & when I moved to another hospital that didn’t use team nursing, it was a really tough transition. But in saying that, I can’t pretend that when you got stuck with someone who wasn’t up to speed in terms of knowledge/experience or was just lazy, it was a tough shift.
I seem to be going against the consensus, but I worked within a team nursing model of care which was fantastic & our patients had good outcomes because of it, in terms of falls, call bell usage, workload management, staff morale & stress levels also improved. Maybe we were the exception?
this team nursing model in the Emergency Dept, is INSANE. Make sure you have good insurance, and get out if you can. Its a recipe for disaster, which you will then be blamed for.
I am currently working a cardiac unit that has team nursing….Mmmm…we have 1 RN and 1 EEN with 11 patients….sometimes if we are lucky we will have 2 RN’s to 11 patients, sometimes 12 patients. I personally think its a shit fight at the best of times. If you work with someone whose communication skills aren’t up to scratch you basically haven’t a clue what’s going on with the patients that you haven’t had time to personally see yourself and if someone becomes acutely ill the one staff member is usually dealing with that the rest of the shift while the other is left looking after the remaining patients on their own….Then one person (usually senior person) hands over the whole eleven patients…things inevitably get missed. It’s even worse when you work with someone whose skills aren’t up to scratch or are lazy and you have to carry them for the whole shift. Or the best point has to be when you have chest drains or pacing wires to remove (which requires two nurses)and you are with an EEN who is not allowed to touch them and you are left looking for an RN with time to help you. It is not safe working practice. Patient care is lacking and it is not effective at all in my view.
team nursing has been implemented to the acute wards where i have worked for a number of years. we are told its here to stay even though we are the nurses who deliver the care to the sick but half the time it should be us in the bed suffering from stress, low moral, physically and mentally run down due to lack of COMMUNICATION. COMMUNICATION IS OUR DIAGNOSIS we should communicate within our team hourly know everything about our patients complete all the paperwork sign the carepaths and write in the pts chart at the end of the the shift and be individually accountable for our actions. doesnt sound like there could be any real issues and if you communicate there would be none. well believe me i can go home and wonder what i have done all day but i have signed my name to the care of all the pts. i honestly cant say i know wholey what has gone on and totally trust all of my team that they have delivered all the cares. when theres an issue the team leader is to blame. you can work within a team of two and get you head around what care has/is delivered. put three or more nurses together and everybody does their own thing. we have had so many senior nurses leave and the ones that are left carry the loafers and the new grads. why do we have to work within this model if we are not happy. pts complain the nurse was rude didnt do this/come back, ive been buzzing. but they will all say we have been running around crazey all shift. HOW DOES IT WORK EFFECTIVELY please i need to know what the secret is so i can continue to nurse before i am the one being nursed
We are currently implementing the team nursing concept and I can tell you I am SCARED! How can there be team nursing when the members of the team can’t play on the same level playing field? Communication is the key and yet we have the WORST communication in this hospital starting from the top down!!!! I cant see how this will work at all. This has been done because it will save the hospital money! BOTTOM LINE>>>>MONEY!! This has nothing to do with patient care. Gos help us all!
I don’t want to go against the grain here but….
Team nursing can work, as long as the people on the floor want it to work. I work in a ward that had team nursing thrust upon it as the result of staff exodus and a ward restructure, and, yes it was difficult at first, but after a while people began to get the hang of it. After working in a patient allocation model for many years, being team leader after hours and having poor new grads looking after people who became unwell all of a sudden, I feel that team nursing is (on the whole) a much better “fit” – at least for our ward. Yes of course you have those days when everything hits the proverbial fan and you have masses of sick leave and a highly acute patient cohort, but you have those anyhow regardless of the model of care that is used. How would it be as a senior nurse having your own (usually technically difficult – you are senior after all!) patient load and having the rest of the ward staffed by casual RNs, ENs and new Graduates, all also looking after difficult to manage patients? A bloody nightmare! At least with team nursing you can have people work together to hopsfully support each other and yourself.
The key to making team nursing work? COMMUNICATION….between the members of the team, between the teams and team leader of the shift, between everyone. Having clear guidelines on how to manage a shift, accountability, responsibility and what level of communication is necessary helps. Having a ward team leader who knows the scope of each staff members abilities as well as the needs of the patient can also help. It can work, but it takes time. Like the ad says “It won’t happen overnight, but it will happen”. At least I know that the new graduate nurses and the casuals on my shift will be supported by another staff member (usually a regular member of staff), and this also promotes learning and development of the junior staff as they can see the way the more experienced RN works. A lot of nursing is learned by “role modelling”.
Yes, it also answers problems posed by budgetary problems and high patient acuity and turnover, but it’s not just about that. It’s about making things safer for those we are here for!
I work in a busy public hospital ICU. They spilt us up into two teams earlier this year. Lots of balloons, senior staff wearing T-shirts, corridor walls filled with team info. Great fuss made of it.
Disaster..6 months down the track. Swine flu and massive senior staff exodus meant it all went to crap. I have been swapped between teams to suit skill mix and patient acuity levels. Don’t bother and save yourself some cash.
did you ever try the team nursing in your ED? we’re trying to do some research on it to see if it works. would love to hear the results if you did try it.
I’ve been on placement this year (3rd year) on a medical ward with team nursing.
Hated it, half the time my buddy nurse hadn’t a clue where they were up to with the patient’s care, not to mention where the “team” was up to.
Majority of the time their was 1 RN and 1 EN for 10 patients. Good ratio on paper, but by the time RN did the first med round for all patients, it was time for the next med round and the rest of the care was left to the EN.
One particular shift I was the most qualified person looking after 10 patients (Hi I’m a student nurse who’ll be caring for you this afternoon alongside RN “I’ll be there in 5 hours”, oh and an affiliate is working this afternoon as well… Good luck pt).
I don’t know how this method of nursing made its way from the drawing board to practice!
I’m Baffled
Interesting comments. Most sound somewhat negative, or rather that team nursing doesn’t work in practice which concerns me since I’m getting ready to attend my first meeting of a team to plan and consider implementation. My hope is that we can lead slackers by example? (no I am not wearing rose colored glasses, just a realist that looks at positive first:))
I have only just strated my nursing training, and this kind of nursing care sounds formidable! The cons STRONGLY outweigh the pros, witht he only pro being it encourages team members to help each other! This is a seriously dangerous form of nursing care! As Matt Mason says, too often things can be forgotten or missed, and in the grand scheme of things, its not worth a clients life to work in a team.
well
this all sounds very depressing, i have been asked to look at this for our Ed.I am starting to wish i hadn’t volunteered.
surely there are some positives?
We are getting ready to implement this type of nursing on our medical floor and I am more than upset and worried. Not that I wish to be critical but I am with you. All I can see is being in charge of more patients with less RN coverage and slackers and New grads who have no clue yet. Seems that doing that math it is all about money and less about patients and their care. I think that it may just be time for a real change as I do not wish to be accountable for the slackers and new ones.
You guys have me scared. we are supposed to implement this in a 2month time period on a ortho floor. What will we do with our slackers. How do you make people realize that they are all grown up and have to work in a grown up world?
i personally hope that this whole exercise is not just to fulfil the agenda’s of the ruling minority.am i paranoid?? perhaps, but take a good look into your hearts and tell me you dont have have similar thoughts!!! i understand that this process will be reviewed in 4 months and i hope that this r/v will be transparent and honest but there is a part of me that continues to believe that reguardless of consequences we as a “team” will be forced to work in an enviromnent that is dangerous to staff and patients alike, i couldn’t be more disheartened with the lack of consultation, and thought given to us mere mortals who actualy do the work. we need to wake up to ourselves they are not listening and they do not care!! so go forth and champion the cause i kinda know that ur being made to but dont look to me or the many other worker bees in the department to help u do it. we have tried it, it didnt work so i know lets try it again and perhaps if we give them scrubs they wont notice how incredibly crap it all is!!
I have worked team nursing in the past and have often left a shift thinking, “thank God no patient was seriously damaged today because of us.”
I remember one shift in particular working a two member per team approach with a nurse whose approach to her job was a cross between Mr. Blobby and an unperturbed cucumber. She was hardly there all shift – long breaks, transfers, or just…didn’t work. It is all very well to try and ruffle her feathers by either myself or senior staff but the motivation of this chick was so lifeless that, “pull your finger out†discussions didn’t count for much when attempted. It’s the old saying, “you can lead a horse to water but you can’t make it drink.â€
The result of team nursing with this absolutely delightful flower was one of the scariest drowning moments I’ve ever endured at work. I had a critically unwell DKA needing one on one care, a chest pain on a GTN infusion who was symptomatic, some poor sod in a C-collar with sacral spine #s, a bed ridden incontinent GOMER needing full care, and a bloke on a heparin infusion amongst other delights. Why didn’t I ask for help you ask? Well, it isn’t easy to get help when the entire department is stretched to the limit with staff diverted to resus and other nurses picking up the slack for their own team short falls all on top of the already evident nursing shortages. There literally, physically was no one. Some “well†patients did not receive any work up for hours, I just had to look at them and see if they “looked†all right and scribble down obs in passing. Would you be happy with this if it was your family member? By the end of that day just imagine a poor sweet young slip of a girl wrapped up in a fetal position under the staff station desk, sucking her thumb, eyes as wide as saucers and mumbling “mummy†– that was me.
It is not safe to think that certain individual staff are going to do the right thing when it comes to team nursing, that the pressure of the team will pull them up. I am concerned that feedback to individuals on their practice still doesn’t focus their motivation for the future. The problem then becomes that the quality of holistic and critical care given to patients is not maintained long term. Once team nursing commences I am apprehensive that loose practice by some may cause serious problems for patients which I have unfortunately witnessed in the past. Furthermore, the responsible ones will be exposed to chastisement for a bad days work alongside the dangerous ones and for what, for doing their own job and someone else’s.
And what happens with the big trauma’s, “can you just come next door to help? The other two in your team will be ok” …for the next 2 hours.
I found with team nursing on the ward that I lost track of where I was up to as far as patient care went. This is due to communication being poor, granted, but I think I would feel lost…
Just number crunching with Iain and the 1 nurse to 3.33 patients does not sound bad but realisticly to aviod 3 RNs stepping over each other there will still be some deligation of responsibilty. Fair enough each admission may be met be 3 RN’s prodding, asking questions, stabbing, hooking them up to minitors. But at some point 1 RN will have to be allocated duties such as medication so that the same patient does not get their meds doubled or trippled. Thus legally the patient becomes the responsibilty of that nurse NOT the team. Granted the team can help out with various other proceedures but as far as I was told at least, once you become responsible for medicating a patient you are legally responsible for that patient.. Period.
So back to the 3.33 patients per nurse, I’d like to ask in the eyes of the law is there such thing as a 1/3 of a human being? So which nurse takes the 4th patient? Answer:
Foot note: Have we not been working in a team anyway?
I have to agree with Punk Nurse – changed to a “team “system in an ED where I used to (and I emphasise USED TO) work. The slack got slacker, and the hard workers burnt out and left . . . . . . . . . . .
I, like your goodselves have reservations regarding the implementation of a team nursing model. My updated information is that the EN’s are not going to be in the model and instead will be utilised in Paeds and EMU. This is unfortunate because on the whole the EN’s are productive workers in the ED and probably deserve better treatment. Using this information the ratio will be 3 RN’s per side, which as Iain mentioned is not too bad in the grand scheme.
The key point as Punk Nurse mentioned is the hard workers will work harder and the slack arses will see this as a licence to sit on their dates and do less. We as a collective have to identify this and speak it out in the open and put the lazy on notice that we are watching and are intolerant of them not pulling their weight.
I think this is going to be a difficult couple of months. Change does not come easy to some and others enjoy complaining and undermining. But it is going to happen despite the multitude of objections raised to the powers that be. Now we can jump on the band wagon and discount it before it has started or we can except our fate, give it a good crack and at the end if/when it has failed our opinion will actually mean something if/when we rain shit down on it from on high.
Can you hears me brothers
Can I get a witness
By the way Mr Miller, being the “champion” of this trial and using Punk Nurses Titanic analogy, You my friend, are Leonardo Di Caprio, chest out and legs akimbo with Kate Winslets breasts pushing into your back, hoping to dear god that global warming has done enough work in your favour iceberg wise.
I have been on a ward which trailed team nursing and I can say that it went just about as good as the Titanic, alot of fan fare, dazzling lights and press but when it came to action…well you can say that the hall of this ward were as icy and trecherous as that cold atlantic night.
We spit the staff into 2 teams, pretty much splitting the skill mix fair down the centre, which was fair enough. Then the patients wr split into these 2 teams, admissions were then flagged to join what ever team to share the workload. Fair enough… on paper.
This is all well on good until you throw in the vairables that nursing does display at times a high turn over of staff, sick leave and some 2 nurses may be at the same skill level but display different how you could say…work ethic. To point the nurses who work hard end up working harder and the slack ones believing their in a team will pick up the slack work less hard.
Then came the vairable that patients get moved around the ward sometime several times in a day or shift, so you end up with 2 patients lying next to each other in different teams. They both press their buzzer. Team 1 nurse is able to reach their patient first, team 2 nurse is tied up elsewhere. Is Team 1 nurse oblidged to help team 2 patient?? Of course and thus the workload increases, as well as the travelled distance trying to cover 3 times as much ground going patient to patient.
It was this fact that lead to team nursing only happening during the morning and evening shifts and at night it was divided geographically thus not a true team nursing model.
It was an absoulte fight for the medical and allied teams to work out who to tell and recieve infomation from as patients and nurses where shufled through the department.
But hey if its going to happen may as well throw the ol life jacket back on and what ever you do dont stop kicking.
My first post was a little short so i thought i should explain myself.
This change to team nursing is all about mathematics and nothing about patient care or best practice.
So here is the equation.
20 Acute beds staffed by 6 RN and 1 EN currently. That’s a ratio of 2.87 pts per nurse. This is pretty good in the grand scheme of things and could and has been much worse in the past.
The plan I have heard of for team nursing would involve the same 20 beds being divided in 2 leaving 3 nurses looking after 10 pts in a team nursing environment. That’s a ratio of 3.33 pts per nurse. Doesn’t sounds to bad really. But the devil is in the detail.
So we as a department will move from 6 RN’s and 1EN looking after 20 pts to 4RN’s and 2 EN’s looking after the same amount. So that’s 2 RN’s per shirt we will be loosing.
Now I don’t want to sound like I am being harsh on the ENs but there is a limit to their scope and that will mean that the roles will probably be divided so that the 2 RNs have 5 pts each and the En floats between all 10. If this doesn’t occur I can’t even imagine trying to keep up with the changing pts in all 10 beds!
So Less Nurses = Less Money spent.
It may sound like I am just reluctant to the idea of change and that isn’t the case at all. I and many others that work in this ED have already tried this (6 pts between 2 RNs) and even on a smaller scale it worked hideously.
The bottom line is health care cost money and lots off it and if you don’t assign nurses to individual pts then you don’t assign responsibility and it will bite you in the arse.
I wonder if Subway is still hiring.
G’day,
I really think that it depends on the size of the team and the size of the ward/department. I don’t think team nursing works if the team and/or the ward/department is too big as things get ‘forgotten’ or missed as ‘I thought someone else would do/had done it’. In a smaller area with a smaller team I think it works quite well as usually you all know what is going on with every one anyway and in effect these smaller units probably do team nursing without realising it. To define smaller (as it is subjective) my personal opinion would be if you have more than three nurses and say six moderately unwell patients and you try and do team nursing the wheels will possibly fall off. Ultimately you do need someone to have a good grip on what is going on with a patient at any one time and it is no good if that person is on their tea break when things go pear shaped. I have found in the past having too many people involved tends to dilute responsibilty. Sorry that this probably doesn’t help you champion the cause.
Cheers Matt
I think i will be “trialing” working somewhere else if we are forced to do this again!