Q: What is team nursing?
A: Team nursing was the primary patient care delivery model in the 50’s, 60’s and 70’s. It was used during World War II when the military faced a nursing shortage and trained ancillary healthcare staff and medics to work in a team-based model, and then it spread to other healthcare facilities. In the team-based nursing model, a nurse who is experienced on the unit oversees the work of a team of clinicians and support staff for a group of patients. The focus shifts from what “I” need to do for my patient today, to what “we” need to do, and who will be responsible for each of those tasks. This allows the unit to serve a larger number of patients, and by sharing the workload amongst a team of people it can help alleviate the stress of one RN trying to care for a group of patients alone.
Crisis staffing models often rely on a team nursing approach as medical facilities redeploy staff to help in areas they may not be as familiar with. This is a tiered approach endorsed by the Society of Critical Care Medicine to manage a pandemic that requires significant critical care resources. In this situation 1 ICU RN may be managing 6 patients with 2-3 RNs from a different specialty as part of the care team.
Q: What are the components needed to make team nursing successful?
A: Designate an expert to lead the team who can teach and delegate tasks, having supplemental staff report directly to that experienced nurse. Establish clear roles that lie within each team member’s professional scope of practice. This allows the experienced nurse oversight of more patients while they have sufficient support to take care of the basic nursing needs of each patient. All team members work together to find innovative ways to manage the care of patients and work together as a team. Each team member focuses on what they CAN do and reserves the specialty skills for the team leader. All team members communicate clearly with each other.
Q: What are the attributes of a successful team leader?
A: The team leader should have experience on the unit, with good clinical and organizational knowledge. This person should be a critical thinker regarding patient care and patient assignments and possess good interpersonal and communication skills. They need to be able to foster a sense of safety in the team, so members are comfortable asking questions or seeking help. They must be able to delegate responsibilities, remembering that scope of practice does not necessarily equal competency, and have a clear picture of the duties, activities, or procedures the recipient of the assignment is authorized to perform within the specific setting. They should maintain clear, direct, ongoing communication with team members and plan for frequent follow-up after delegating tasks.
Q: What should a team leader know about Delegation?
A: The RN must know what they cannot delegate to non-RNs, using the 5 “rights” of delegation: right task, right circumstance, right person, right supervision, and right direction/communication.
According to the Oregon Nurse Practice Act, Division 45: Standards and Scope of Practice for the LPN and RN, The RN may assign to another RN or an LPN nursing intervention that fall within the scope of practice and that the licensee receiving the assignment possesses the competency to perform safely.
The RN may assign the CNA authorized duties identified within Division 63 of the Oregon Nurse Practice Act: Standards and Authorized Duties for the CNA, that the certificate holder possess competency to perform safely.
An RN may assign an unregulated assistive person (UAP) work that they are authorized to perform within the setting and that the UAP possesses the competency to perform safely.
The RN should continue to provide supervision to team members to whom they have delegated tasks, ensuring documentation is complete. They should continue to evaluate the effectiveness of the assignment, revising the assignment as indicated by client outcome data, availability of qualified personnel and available resources.
Q: What could a successful team look like?
A: Team members could include critical care nurses, medical-surgical nurses, perioperative nurses, certified nurse anesthetists (CRNAs), pediatric nurses, pharmacists, respiratory therapists (RT), physical/occupational therapists (PT/OT), certified nursing assistants (CNAs), patient care technicians, nursing students, etc. Successful teams should utilize the strengths of all health care professionals in order to provide the best possible care to patients.
For example, CRNAs and RTs could take on ventilator management, pharmacists could do medication reconciliation, pediatric nurses could be the go-to resource for family communication, PT/OT could help with repositioning, ambulation and toileting, etc. Every team member uses their unique skills and abilities to provide complete care to the patient. The team leader is responsible for making care assignments, utilizing everyone’s talents and core competencies, and supervising care given by others. As a team member, you are responsible to accept only RN assignments that are within your individual scope of practice.
Q: What about documentation?
A: Each team member should be responsible for documenting the specific type of care they are giving. The team leader should be responsible for the overall patient assessment and care planning or could co-sign an assessment done by another RN.
Q: If I am asked to move to a team nursing model, can I refuse?
A: Because of the Governor’s Executive Order and OHA’s emergency guidance, all staffing plans may be suspended during the immediate crisis, so changes in care delivery are likely. Team nursing is a viable model, if done correctly, so a nurse must always use their best clinical judgement when assessing a patient assignment. The OSBN has recently addressed this concern through their interpretive guidance.
- The primary consideration is whether you possess the knowledge, skills, and ability to perform the assignment safely.
- Your judgement should include whether there are policies and procedures in place that clearly define your role and escalation of concerns.
- Your judgement should include whether or not a reasonable and prudent nurse would accept the assignment.
- Finally, you should consider if the format provides the safest care delivery possible within the current constraints.
- Refusal of an assignment may put patients and nurses at increased risk of harm and license discipline is always possible in the current crisis climate, so you must be able to clearly articulate the reasons for your refusal with as much evidence as possible.
- Remember, once an assignment is accepted, you may not leave that assignment unless the care of those patients is transferred to another capable nurse or it would be considered patient abandonment.
Q: How can I determine if an assignment is safe and within my scope?
A: This question is similar to the question regarding the safety of a team nursing model, and it is helpful to refer to OSBN’s Scope of Practice Decision Tree. Ultimately, the nurse must determine if they have the knowledge, skills, and ability to safely perform the assignment.
Q: We are moving to a team nursing model, what steps can I take to prepare?
- Read and familiarize yourself with the Oregon Nurse Practice Act.
- Know the skills and competencies of your team members and what lies within their individual scope of practice within the practice setting.
- Ask for training on working as part of a team with clear delineation of roles and responsibilities.
- Ask for decreases in expectations (as written policies, practice alerts or protocols) when there are increases in patient assignments, acuity, and work intensity with fewer resources.
- If you don’t have it already, consider getting malpractice insurance.
- Consider keeping a journal to document your experiences.
- Continue filling out SRDFs and/or OHA complaints so we can continue tracking data.
You can also utilize the resources below.
Additional Resources:
https://www.nursingcenter.com/ncblog/march-2020/alternative-staffing-and-onboarding-models
https://www.nursingcenter.com/ncblog/december-2020/team-nursing-model
https://www.aacn.org/blog/team-nursing-and-covid-19-surge-staffing
https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/nursing/meetings/2020/tiered-staffing-strategy-Hulin.pdf
https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/HEALTHCAREPROVIDERSFACILITIES/HEALTHCAREHEALTHCAREREGULATIONQUALITYIMPROVEMENT/Documents/NSCovid19ImpactsMemo.pdf?utm_medium=email&utm_source=govdelivery
https://www.oregon.gov/osbn/Pages/laws-rules.aspx
https://www.oregon.gov/osbn/documents/IS_PatientAbandonment.pdf
https://www.oregon.gov/osbn/documents/IS_Scope_Decision_Tree.pdf
