Assignment Practices that Support Primary Nursing

1. Assignment Practices that Support Primary Nursing Creative Health Care Management Teleconference, January 2009 Susan Wessel, MS, MBA, RN, NEA-BC www.chcm.com

2. Leaders must: • Provide appropriate staffing: • stable staffing • flexible systems • appropriate skill mix • schedules that focus on the needs of the patient • competent staff

3. Leaders must: • Manage for continuity: • of assignments • of team mates

4. A crucial role of management… establishing a ‘Stable Infrastructure’ for safe patient care

5. Assignment Decisions Impact Primary Nursing • System can: • support primary nursing • serve as a barrier

6. Hallmark of Primary Nursing Clarity of Roles and Responsibilities

7. The RN Determines • Kind and amount of nursing care the patient needs • How much of that care can be delegated

8. Primary Nursing • Reinforces these responsibilities • Allows important gains related to consistent relationships

9. History of Pairs or Partners Assignments • RNs often work in isolation • Need was first identified by Marie Manthey in the 1980s* • Brings caregivers into collaborative practice • Supports role clarity and appropriate delegation *Manthey, M. (1989). Partners-in-Practice: A logical extension. Minneapolis, MN: Creative Health Care management.

10. Pairs and Partners:Impact on Caregivers1 • Increased efficiency in work • Natural synergy • Staff report a 25% reduction in workload and stress • More knowledge about each other’s competence • foundation for delegation 1 Wessel, S., Felgen, J.,Person, C., & Kinnaird, L. (2008). Care Team Pairs and Partners in Primary Nursing and RBC. Unpublished White Paper, Creative Health Care Management.

11. Impact on Caregivers (cont) • Improved communication* • Team • Other shifts • Other departments • Increased commitment to each other • Increased ability to deal with more complex situations • Propensity to support each other’s continued learning and advancement *over 50% of sentinel events are related to communication errors

12. Consider Three Methods of Making Assignments

13. Method 1: Unit Based Assignments • Assistants: • serve most or all RNs on the unit rather than getting direction from one or two • carry out the same activities each day, as if they own the work rather than the RN having responsibility for it (e.g. RNs may not be actively considering whether they should take vital signs on some patients)

14. Method 2: Pairing • One RN working with a nursing assistant, LPN, technician or other care assistant • Pair cares for the same group of patients just for today but not necessarily for tomorrow

15. Method 3: Partnering • One RN is consistently scheduled to work with another caregiver • Stay together by choice • Coordinating schedules to the degree realistic • Commit to maintaining healthy interpersonal relationships • Recognizethe RN has the authority to make the delegation decisions

16. The utilization of auxiliary personnel needs to be done in a partnership or a paired system. Then we don’t have people running around doing a lot of tasks, but rather we incorporate them into a holistic perspective of care for a group of patients under the direction of a knowledgeable RN. Marie Manthey Creative Health Care Management, (2002). Staffing: changing the way we think. Minneapolis, MN: CHCM

17. Paired or Partnered “Frame of Mind” • Caregivers: • See the patients as their collective responsibility • Make the most of one another’s contributions • Care for ‘our’ patients… not ‘yours’ and ‘mine’

18. Care Team Partnership Arrangement • A more intentional consistent relationship than paired • Because the partnership is stable, members: • learn each other’s special talents and work preferences • communicate more effectively • provide for each other’s growth • May be times when the care team is not working together, but this is the exception

19. Mini-refresher on Delegation Principles

20. Delegation Responsibilities1 • RNs are responsible for their decisions about what to delegate • RNs are not responsible for the faultless performance of the delegee: • Delegees are responsible for their own actions 1 Forstrom, S. & Weydt, Al, Eds. (2008). Work complexity assessment facilitator’s manual. Minneapolis, MN: Creative Health Care Management

21. Delegation Principles • RNs are responsible for using good judgment when delegating regarding: • Knowing everyone’s scope of practice • Matching the work to delegee competence (key) • Giving timely data, instructions & feedback • Being available to answer questions • Follow-up to see that the work has been competed satisfactorily

22. Building Partner Trust • Use conscious practices • Verbalize what is appreciated about the other • Regularly ask for their observations and input • Offer to help them when they need it • When delegating work to another, find out if they are able to accomplish it; are there any barriers • Remember, assigning responsibility is a two way process • Thank them for their contributions

23. Conclusion Primary Nursing is a commitment to the professional responsibility of the RN for the individualized care of the patient and family for their length of stay in a department

24. One can expect significant gains in productivity, teamwork and appropriate delegation, among other things. This is supported by assigning staff members in pairs or partnerships whenever possible.