Premier pediatric hospital develops primary care nursing model
This is what nursing is all about’
(Editor’s note: Only six health care systems in the nation have received the Magnet Nursing Services Recognition Award from the American Nurses Credentialing Center in Washington, DC. This prestigious designation acknowledges quality of patient care services and the development of successful, professional nursing practices and strategies. For example, University of California, Davis Medical Center in Sacramento uses a model of primary nursing to provide individualized yet consistent care to children and their families.)
A new primary nursing model has resulted in increased patient, family, and staff satisfaction as well as improved pediatric outcomes, says Lynne Boehret, RN, pediatric manager at UC Davis Medical Center in Sacramento.
"In the first three months, medication errors decreased by 50%, and incident reports were fewer," says Fran Malloy, RN, assistant nurse manager.
In this model, each patient is assigned to a primary nurse who follows the child during current and subsequent admissions.
"A primary nurse not only provides all bedside care but also develops and coordinates plans of care for three to four patients at a time," says Boehret. "Because we work 12-hour shifts with significant splits between days, an associate nurse stands in for a primary nurse when he or she is not on duty."
The average patient who is hospitalized for three to five days will see a minimum of two nursing staff, explains Boehret. "Each patient has one nurse and the remainder of the nurses sign up to be his or her associates," she says.
For example, a child who recently was hospitalized for three months had one primary nurse and six associates who were consistently assigned to provide care. Following a six-month pilot program, the model became a standard of care in April.
Previously, it was difficult to maintain consistency in care delivery because nurses worked two to four 12-hour shifts per week."When I walked into a room and a distraught mother cried that I was the 54th nurse, she’d seen in 30 days, I knew it was time to make a change," explains Angie Marin, RN, BSN, assistant nurse manager.
The staff knew from anecdotal reports that many "little things" added up to make parents unhappy about the continuity of care in the old model. "They were frustrated with having to tell a different nurse the same concern over and over again," she says. "Perhaps their child was toilet trained, yet we diapered him. Or maybe he liked his meds with applesauce and we brought juice."
Such dissatisfaction is magnified when lengths of stay are extended. "We’re a designated pediatric trauma center serving children with multiple injuries and we also have a population of chronically or terminally ill children that require repeated readmissions," Boehret says.
Who’s on your team?
To provide consistent nursing staff, Boehret, together with Marin and Malloy piloted, evaluated, and then fully implemented a primary care nursing system with these elements:
1. Teams of primary and associate nurses.
Primary nurses are responsible for collaborating with other health care team members, coordinating care conferences, identifying and planning for discharge needs, and developing an individualized teaching plan for the patient and family.
However, the primary nurse is different from a case manager in that the latter does not generally provide direct bedside care, explains Boehret.
"All career RNs those who are hospital employees who receive benefits and are hired for pediatric positions on both shifts are designated as primary nurses," says Boehret.
Nurses who have just graduated or those newly hired for a permanent position on the unit serve as associate nurses to carry out the plan of care when the primary nurse isn’t available. "They may alter the plan of care based upon the patient’s changing needs," she says. (Primary care nurses can also assume responsibility for functioning as associate nurses for a caseload of patients when that patient’s primary nurse is not on duty.)
Per diem nurses, experienced pediatric nurses who are employees but receive an hourly wage and work during times of high census, are designated as the primary nurse for patients staying less than 48 hours. Per diems can also function as an associate for any patient covered by their teams. (For more information on UC Davis per diem staff, see story on p. 138.)
2. Color coding assignment system.
The nursing staff is divided into four color-coded teams of about 10 to 12 nurses each. The team’s colors correspond to pens used on the patient scheduling board. An administrative nurse ensures balanced team coverage and compiles master schedules.
Primary patients are not assigned to any one area or even in the same room. "We found that geographic grouping resulted in territoriality," says Marin. "It actually built cooperation among teams not to have two primary patients in one room. Primary nurses developed an informal buddy system’ and looked out for each other’s patients."
3. Balanced, well-led teams.
To ensure effective teamwork, the primary nursing committee surveyed nurses to identify levels of expertise and interest before dividing staff into teams.
Teams do not change or rotate members from week to week, but remain consistent. Also considered as factors in team distribution were individual scheduling preferences, as well as professional and personal strengths. Finally, the committee selected a Clinical Nurse III to serve as team leader a captain responsible for coordinating the activities and facilitating teamwork within each assigned group. "These nurses are highly experienced pediatric nurses who serve as clinical role models and mentor for the nursing staff," explains Boehret. "They also function as primary nurses for their own caseload of patients in addition to providing resources for members of their primary nursing team."
What about nursing aides?
Although this hospital has a skill mix of 95% RNs, Marie Manthy, founder of the primary nursing concept, points out the model does not preclude using LPNs and aides.
"Primary care nursing is not about all-RN staff. It means a nurse accepts responsibility for managing care of small patient caseload over time," says Manthy, founder of Creative Healthcare Management, in Minneapolis.
The secret to using unlicensed assistive personnel (UAPs) is to assign them to nurses, not patients or tasks. "There must be a relationship between the RN and the UAP who work in a partnership to take care of patients," she says. "Nurses and aides who work together on a select patient load build trust and communicate more effectively; the aide can become the eyes and ears for the nurse."
Without this partnership, the aide may be focused merely on tasks and may not even know to report observations such as change in color and clarity of urine, which may indicate major problems.
No matter what the skill mix is, accountability for overall care still belongs to the RN, stresses Manthy.
"The concept is simple, but the change isn’t easy," she says. "It requires better teamwork than any other system. And if there is a morale problem, you’d better fix that first or it will destroy primary nursing."
Other impediments to implementation include management being unwilling to let go and give the bedside nurse the authority for patient care, Manthy says.
Primary nursing demands professionalism
Boehret had dreamed of implementing primary nursing for 10 years.
"We had never actually reached a point prior to this pilot where we were successful in obtaining staff buy-in to even trial the primary nursing concept," points out Boehret.
Primary nursing, explains Boehret, requires a strong professional commitment from each member of the nursing staff. "The nurse can no longer shift responsibility for planning care or teaching a patient to the next shift," she says. "Without staff nurses committed and willing to practice nursing at this level, it’s not possible to succeed."
This time, however, the "grass-roots momentum was building," says Malloy. "Staff nurses, who watched the trend toward changing skill mix, wondered how they could most effectively demonstrate to the consumer as well as to hospital management that an RN has a significant and vital role at the beside." About the same time managers began to notice an increasing level of patient dissatisfaction with the continuity of care.
By the first staff meeting of 1996, the stage was set for a successful primary nursing model. "At our first staff meeting of the year, nurses volunteered to look at various models of care delivery in an effort to identify one which would improve continuity of care and fully utilize the expertise of the RN as a direct care provider," says Malloy.
After choosing the primary nursing model, committee members also conducted a literature search to identify other children’s hospitals with the same delivery system.
Although several pediatric units were providing care within the framework of primary nursing, they didn’t have 12-hour shifts to contend with.
After writing a proposal for a pilot, the group recognized that understanding the theory of change was vital to the success of this project. "We asked experts within our health care system to prepare the committee members for staff reactions to change as well as explain how we could most effectively deal with the fears of staff and any resistance which comes with change," says Malloy.
Staff buy-in is the key to success
Buy-in, ongoing communication, and education, Malloy and Marin agree, assured a successful implementation. "We constantly asked staff for input; we posted flyers, we sent letters, we held monthly open forums to allow staff the opportunity to share frustrations or fears they may have had," Marin says. As part of the pilot design, the team also designated a resource person on every shift who could serve as a "resident expert" and role model for primary care nursing.
"These key individuals were members of the primary nursing committee who had been involved in the planning process from the beginning," Marin adds.
Staff are happy with the primary nursing system. On a post-implementation survey, 72% reported they were strongly satisfied or satisfied with the new way to render patient care, Boehret says. (See copy of nursing survey on p. 136.)
The committee members also emphasized the importance of written communication to promote consistency among team members. The resulting "communication sheet" for the patients’ chart which contains a section for the primary nurse to list key points that are important to the family or patient. "It has decreased our parent complaints as well as our reporting time because the information we need is right in front of us," Marin explains. (See form, above.)
To assess how the new model affected staff and patient satisfaction, the team designed a pre-discharge questionnaire for parents and adolescents as well as a parent phone interview conducted 48 to 72 hours post-discharge. They evaluated the parent/adolescent perceptions before and after the pilot project.
"What we found was that it was indeed helping us to provide consistent care," says Malloy.
In addition to overall reduced length of stay and reduction in patient complications and incidents, there were fewer readmissions because of unclear discharge teaching or failed home health coordination, adds Boehret.
Work efficiency has increased also. "While we have not changed our staffing patterns, we are seeing efficiencies at both unit and systems levels," she explains. "As nurses spend less time collecting data because they know their caseload so well, they can spend more time on planning and implementing care."
But the real benefit is an intangible one. "We began to see patients as individuals with unique needs and not just a DRG. We discovered that nursing was much more about building trusting relationships. In turn, patients and families developed a bond with us. This is what nursing is all about."
[Editor’s note: For more information, contact Lynne Boehret, UC Davis Medical Center, 2315 Stockton Blvd., Sacramento, CA 95817. Contact Marie Manthy at Creative Healthcare Management, 614 E. Grant St., Minneapolis, MN 55404. Telephone: (612) 339-7766. Web site: http://www. chcm.com.]
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