In my next staff nurse job we did “primary care” with an all-RN staff. We still I was reminiscing the other day about my first job as a staff nurse. I felt I was really part of a team. I did team nursing. The RN did the assessments and IV's. The second RN, or LPN, did most of the meds and treatments. The tech did the vital signs. At the start of each shift, the whole staff received a group report, decided on assignments and planned the work. My whole team knew about all our assigned patients as well as what else was going on in the department. We usually worked with the same team members and we got to know each other well, even socializing together outside of work hours. We were accountable to each other. If there were conflicts, we worked them out because we liked each other. The team had fun doing work together. We had more opportunity to get to know our patients. It seemed like patient needs were better met. The team had good communication among ourselves and those we interacted with in our jobs. It was rare to miss a break or meal, or worse yet... miss bathroom breaks. After all, we trusted our team members to manage in our absence.
In a later staff nurse position in another hospital, we did "primary care" with an all-RN staff. We still took report together as a group. Our charge nurse made assignments, based on our requests and some effort to maintain continuity of care. But… breaks were often missed as it was necessary to find another RN who was willing and able to “watch” my patients as well as her own in order for me to leave the unit. There was more of an “every woman for herself” attitude. We worked essentially in isolation with our assigned patients. There was still some socialization with co-workers, but there was not as much accountability and trust among us. We didn’t really spend much time together.
By the time I left my last clinical job, much more had changed. Group shift report still existed, but barely. It was so condensed it was almost non-existent. It was eliminated in some areas of the hospital altogether and was replaced by a process of staff individually accessing information on the computer about their patients. Assignments were made by the off-going charge nurse, even before I ever got to the hospital. Little consideration to staff requests or continuity of care existed because the off-going charge nurse did not have that information. Again, it was an all-RN staff and we worked essentially in isolation. Missed breaks were often a problem. Accountability, triangulation among staff, unresolved conflict, inattention to results, and lack of trust were bigger issues.
So looking back over my own 22+ years of clinical experience, the conditions for true teamwork to flourish have dramatically deteriorated. Patients and assignments have changed. But I believe the larger impact is that opportunities for obtaining needed information and socializing with co-workers have begun to disappear. Cost-saving measures have resulted in shortened or eliminated group reports. Nurses are provided with only the minimum information they need to take care of their own assigned patient group. Access to information about what is going on in other areas of their unit has diminished as a result of confidentiality issues and/or lack of shared report. I believe that lack of teamwork and socialization opportunities have impacted accountability, conflict resolution and trust. These are essential elements for true teamwork and highly functioning teams to emerge. So… if you want more “teamwork” from your staff, finding ways to restore these elements seems like a logical place to start.
What I have described above applies to my own experiences in acute care hospital units, but I’m betting the same factors influence care teams in almost any setting. So how can we make this better? And how can we make the patient a part of this team?
