[Sharon]

Reflect on your work experience and environment. Thinking of the research you just read on teamwork which is 10 years old now and reflecting on your work experience and environment; identify and post recommendations that have been implemented. Have they been successful?

[Jacqueline]

I recall working in the hospital on the medical floor many years ago. When I had first started on the floor we worked in teams, RN/RPN – each of us had our own assignment but you would cover each other and support as needed. We also had PSW support at times. If your team had coverage from the PSW, you would have an increased pt/nurse ratio. And if no support from the PSW your pt/nurse ratio would be reduced by 2. It was a difficult assignment even with the addition of PSW support. The extra patients to provide care for were becoming increasingly complex as time went by. After much feedback for increased PSW supports for all teams, unfortunately there were budget cuts and the PSWs were removed from the floor. It was noted from management that by removing the PSW’s there was increased budget to add more nurses and thus reduce the pt/nurse ratio. Not all of this actually happened. The PSW’s were removed from the floor, a few nurses RPN were hired and the pt/nurse ratio stayed the same as previous. In this instance the team environment failed as management / leadership failed to provide adequate team supports.

[John-paul]

Hi Jacqueline,
Thanks for sharing your example. It sounds like this recommendation relating you the teams composition and models of care did not go as planned. It can be tough when things don’t go according to plan. How do you think management could have supported these changes differently? Was there and evaluation of the plan while/after it was implemented?

[Jaclyn]

In my workplace a few years ago, a similar instance to Jacqueline’s occurred. We use to have 7 patient assignments for nurses and 3 PSWs to support on day shift. A PSW was removed to add in a 8th nurse to decrease the nurse to patient ratio. However, the unit census was increased so even with 8 nurses instead of 7, they actually had more patients in their assignment compared to when there was 7 patient assignments and 3 PSWs. Currently the manager is removing the 8th nurse without adding the 3rd PSW back. The nurse/patient ratio has increased severely impacting the safe and quality care nurses can provide to their patient’s. This has impacted the morale of the unit as the nurses are frustrated and often leads to tension and conflict within the team, especially when needing the limited PSW support offered. There is also an expectation for the nurses to have patients transferred into their wheelchairs before or immediately after breakfast so they can participate in their rehab. This is very difficult with all the other responsibilities nurses have to provide. The interdisciplinary team has poor communication and are not supporting one another to therefore improve the patients’ outcome.

[Jacqueline]

Its unfortunate to think that budget and safety should be considered in the same sentence together when looking at nurse to patient ratios. I always thought that something serious needed to happen, some serious error or act before anyone would step in and say “enough”. Look at the reports that came out from LTC during covid. There had been rumors for a long time about neglect and lack of resources, resident care was defined in minutes – none of this seems appropriate, none of this seems right. But, look at the nurses still working under these conditions, under the mounting pressures, stresses and strains to still provide care, we have shown that we can still do it, still provide care. Thinking about not providing care isn’t even an option. The stories that I have been sharing from my time in hospital were over 15 years ago, what has really changed since then?

[John-paul]

Hi Jaclyn and Jacqueline,

It is quite unfortunate to see this re-occurring theme. When I first started working at the hospital, I had heard the unit used to have PSW’s scheduled for almost every shift. This has come back throughout COVID and the unit workload seems a lot more manageable; hopefully they continue to schedule PSW’s in the future.

There are many changes that have happened before and throughout the pandemic and although it’s tough to hear about, I am hopeful that a light being shone on these issues will bring some positive change for the system. Thank you both for your hard work and commitment to the profession through all the challenges we have faced and continue to face.

[Josephine]

Having started my nursing career in rural Northern Ontario, I can relate to the statement ” social interaction inside the workplace strengthens professional relationships. Nurses in rural areas indicated they often know each other outside work. Workers in larger organizations, particularly in urban areas, must rely more heavily on casual interaction in the workplace”. Working in a rural hospital the nursing team had the attitude of ” all hands on deck”! The team viewed RPNs as an essential and critical component to deliver nursing care. In fact, our staffing model supported X1 RN and X2 RPNs on the acute floor and X2 RPNs on the complex continuing care unit, and X1 RN in ER. In a rural hospital, we are limited in resources and accessibility to care for example if a patient needed a CT scan, the patient would have to travel 1 hour to the nearest city hospital to have this diagnostic image done. If a trauma came in i.e. motor vehicle accident, we would put an urgent call to Orange airlines to fly them to the nearest operating unit and or arrange for a Critical OTN consult to direct our physician and team on what to do with what we have until the advance care team arrived. It wasn’t until I moved south, and worked at an urban hospital I realized just how specialized every unit and department was – access to ICU, CT imaging, stroke, and rehabilitation ect. was mind-blowing and in some ways intimidating. I recall my first code blue at the urban hospital over 50 staff showed up -physicians, rapid response nurses, logistics, respiratory therapists, social workers ect. meanwhile, in the rural hospitals, the RNs and RPNs were it! again “all hands on deck”!

In a rural hospital, your teammates truly become your family. I worked with my teammates more than I saw my own family. My teammates and I would see each other outside of work grocery shopping or ice fishing on the lake. A town of 2,500 people you were bound to recognize or be recognized by someone. The work culture in a rural setting is very much different compared to an urban setting. I never felt more isolated, undervalued, and unappreciated when I worked at the urban hospital – sink or swim mode was the tone of the workplace. I worked with managers who didn’t even know my name, and staff I never met before, and got pulled to float to other units. I n I was point-blank miserable for 3 years, hated nursing, hated my job, and on top of a pandemic working the front line … I broke! I lost faith in the organization I worked for, I did not have trust in my team or leaders and above all, I was not valued as an employee. Despite all this, leaving the urban hospital was not an easy decision. I was wrestling with the choice to continue my nursing career – to renew my license or not? Do I go back to school for a second career? Do I take a break or find another job? financially, I was the breadwinner for my family, my husband was out of work because of the public shutdown. How can I give up my full-time job now? Ahh, so many things to consider.

After much consideration and weighing the pros and cons, I left the urban hospital and found a job as a nurse leader. I knew despite my experience working in the urban hospital I was a dam good nurse! It was unfortunate, the work culture could not being out the best in me, my skills and my knowledge.

Now, I work as the Director of Wellness for a retirement lodge and work alongside unregulated professionals UCP ( personal support workers and resident attendance). My leadership style embraces mutual trust and respect among all team members. For instance, if the kitchen is short, I will help to pick up dishes and put a load through the dishwasher. I wear scrubs once a week to help out on the floor and directly work with the residents and staff members. Doing this allows me to understand the challenges and barriers of care directly in an effort to find a suitable solution. I praise my team by sharing feedback from residents and families, writing a ”shout out” note, or giving a gift card as my way of recognizing and valuing each team member. I have daily huddles with the team to communicate changes, upcoming education, goals, staffing needs, and concerns. When onboarding new hires, I pair up with them as my way of mentoring them to their new role as well as with a season UCP worker. In the event of a medication incident, I use a coaching approach to help facilitate their learning to identify how the error happened and strategies to prevent it from happening again.

I agree with my peer Jacquelin’s discussion post ” it’s unfortunate to think that budget and safety should be considered in the same sentence together”. I go over budget and extend myself to the team to demonstrate the respect I have for their role. I always say “without my team… I am nobody”. This was very much a true reality for me last year when unforeseen changes happened to my team. Staff found other employment opportunities, staff quit without reason, staff absences were on the rise etc. At one point, staffing got so critical I called on my regional manager to help me source out a staffing agency. I was opposed to bringing in agency staff but my existing team was burning out, morale was down, and resident care services were delayed. The problem at hand was larger than I could imagine. I blamed myself and my ability to lead. Why are the staff leaving me? I now understand it’s not a direct reflection of me. During my exit interviews staff were leaving because of multifactor. At the same time, rerouting let alone retaining staff was very difficult. I would go weeks without a single resume posted on the job board or I would schedule an interview and they turned out to be a no-show. This went on for weeks to months. I did eventually secure an agency staffing and it was a bandaid solution until I could build my own team up again. having gone through this experience, now have all lines filled and then some. I have brought in 3 casual workers to help pick up shifts in the event of a sick call, or emergency, I am able to offer days off and vacation time to my full-time staff because I can cover their shifts. Moreover, I reviewed the schedule of resident care and services and re-arranged their care plans to help support my staffing needs. For instance, I do not have any showers/baths offered on Fridays, Saturdays, or Sundays because, over the weekend, management is not there if I can take tasks away from staff in an effort to help them fulfill their duties and responsibilities without getting overwhelmed or stressed out. In turn, this demonstrates I am flexible and understanding of their position and in turn, staff works twice as hard to exceed and execute resident care because I value and respect the work of the front line. When I started my journey as a nurse leader, I promised myself I would never forget my roots as a front-line worker.

[John-paul]

Hi Josephine,

Very detailed post and some great examples of the differences in staffing models and team composition between rural and urban hospitals. I found this very interesting and although I have thought of this before, it was neat hearing it from someone who has experience working in both urban and rural healthcare settings.

It was tough reading about the negative experience you had working in an environment that didn’t feel supporting, with a “sink or swim” mentality, however I am glad you hear you’ve entered into a leadership role where you really seem like you can support the team in so many ways.

You sound like a very supportive manager that supports a team to allow them to be high-functioning! Although you have had some staffing difficulties, you rose to the challenge and identified the resources that were available to you to find solutions until long-term solutions could be developed. Thank you for all the work you do supporting your staff and clients and the system as a whole.

[Veronica]

Five years ago I worked in a long term care facility as LPN. Each care unit with 30 residents has 1 LPN and 2 CCA’s and a float CCA that helps between care units. I only worked for evening and night shifts. It’s true that we have regular residents so the routine is the same every shifts however you always have to anticipate for emergencies, anything can go wrong and when it happens having good teamwork is very beneficial to be able to finish the tasks and deliver the meds on time to residents. Sometimes when a CCA call in sick and cannot find replacement I have to help the remaining CCA on her task while doing my own and for me it makes the work less stressful if you get along with your co-worker and proper communication is very important to ensure service is delivered accordingly. I think the management in this facility tried their best to the make the nurses workload less stressful by hiring a float LPN during the day and the RNs are always available to help out when needed.

[John-paul]

Hi Veronica,

Thanks for your post. Do you think that changing the staffing module and having a float LPN during the day was a successful at creating a team that was able to function at a high level? I would be curious to hear your thoughts.

[Alison]

Similar to Veronica, I work in LTC. We have recently undergone a revamp of staff to resident ratios and distribution of residents throughout the building. 2 years ago I had 60 residents to give medication to, assess, document on, perform wound care for, etc. I worked with 7 PSWs and 1 RN who floated between my unit and the other (of about 51 residents). As residents became more complex or faced situations outside of their norm, the RN assessed and took over aspects of their care. Now the building is divided into units of 32 residents. This sounds easily but there are 3, soon to be 4, units that the RN floats between. Many of the tasks that used to be performed by the RN, ex catheter care for all residents in the building, now falls to each RPN because “she only has 32 residents”. The residents needs are more complex and their families are more involved all the time. The RN continues to be available for support or assistance but myself, and I think others, feel that although we have less residents, we are doing more work than previously.

[Author]

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