the myths and assumptions about team nursing

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by Margaret Aasterud Williams, R.N., M.S. “Do you have teum nursing in your hospital?” “Oh, yes. We started it two years ago.” “How is it working out?” “Why, very well. We’re pleased with it.” “Has putient care been improved?” ‘‘Well, I don’t know for sure, but I think so.” “Are the nurses more satisfied - has the turn-over rate “Weil, no, that’s stuyed the sume. But I think everyone decreased?” likes the system.” NURSlNG FORUM 61

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by Margaret Aasterud Williams, R.N., M.S.

“Do you have teum nursing in your hospital?” “Oh, yes. We started it two years ago.” “How is it working out?” “Why, very well. We’re pleased with it.” “Has putient care been improved?” ‘‘Well, I don’t know for sure, but I think so.” “Are the nurses more satisfied - has the turn-over rate

“Weil, no, that’s stuyed the sume. But I think everyone decreased?”

likes the system.”

NURSlNG FORUM 61

H E “system” of team nursing is looked upon by many hospitals as a hoped-for solution to numerous patient- care and intra-staff dilemmas. The myth of its won-

drous attributes is perpetuated within nursing schools, where students, in their discussions, tend to lament the impractic- ability of the case method of personnel assignment, deplore the functional method, and extol the team method, which they see as a primary answer to major problems of personnel utilization and as a means of raising standards of patient care.

I believe, as do many, that team nursing can be an exciting outcome of endeavors to cultivate the basic human factors within the hospital. In itself, however, it is seldom the cause of positive developments; rather, the positive outcomes are the result of constant effort to nurture the bases upon which any successful administration is built. Without this nurturing, team nursing itself tends to fall flat.

Team nursing fails to live up to the claims made for it when it is nothing more or less than a system for assigning person- nel or when it is merely a “wordfact.” The team nursing system in this latter category can be a convenience and mean merely a total saving in energy, since, according to Galbraith, “The wordfact makes words a precise substitute for reality . . . it means that to say something exists is a substitute for its existence. And to say that something will happen is as good as having it happen.” ( 1 )

Sometimes it is more politic for a nursing service to make team nursing a wordfact than to admit to its absence, A nurs- ing service which cannot say, “Yes, we practice team nursing here,” may be considered by the nursing community to be unprogressive and undemocratic. So strong is the verbal ac- ceptance of team nursing in any form that a negative response to questions of its presence is frequently made defensively

T

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and followed with immediate “because” or “but” elaborations. As a method of decentralizing authority, the structure of

team nursing is administratively sound. No one need apolo- gize for employing this method of personnel assignment, but to grace such a method with the appellation “team nursing” is questionable unless certain assumptions about the charac- teristics of the team nursing system are borne out in fact. More often than not it is taken for granted that these as- sumptions apply to any situation that bears the label “team nursing.” Perhaps an appraisal of the actuality of these as- sumptions is overdue.

ASSUMPTIONS THAT A R E FREQUENTLY UNREALIZED

Assumption No. 1: Team nursing is nut a method; it is ci

philosophy. Observation of varied nursing units that are supposedly

practicing team nursing will convince the most skeptical that this assumption is frequently not borne out, or that it is true for only eight of the twenty-four hours. When the over-all institutional philosophy ignores the doctrine of “using the best capabilities of each individual for the patient’s benefit,” it is difficult for individual nursing units to operate in accor- dance with this stated philosophy. Occasionally, even under adverse conditions, a single unit, because of relative isolation, insulation, or strong personalities, may become almost a showpiece for team nursing, but an optimum level of func- tioning is difficult to maintain for long without support from somewhere.

Assumption No. 2: The conference is the heart of team nursing.

If this assumption is a valid one, many nursing teams are

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suffering from acute decompensation. The fact of the matter is that conferences are frequently omitted. The stated reasons for the omission usually involve time, for example, “There doesn’t ever seem to be a good time to meet,” or, “We were going to meet, but everyone was so busy at that time.”

There is no denying that time is precious, and too often it is true that nurses and auxiliary people spend their entire day racing the clock in an attempt to carry out the myriad tasks confronting them. However, most of us find time for ac- tivities which we do well and, in the performance of which we are relatively comfortable, and avoid anxiety-producing and uncomfortable situations in which we are not at our best. It is likely therefore, that another factor is operating, namely, staff nurses frequently feel unqualified for and uncomfortable in leading conferences. Moreover, because of this feeling of inadequacy on the part of the team leader, when a conference is held it often is utilized only as a medium for auxiliary per- sonnel to report to the team leader what tasks have been completed and the amount of care given to whom, for the passing out of information and directives coming from nursing administration, physicians, and other departments, or for the pooling of information solely for information’s sake. These activities may well be a part of the conference, but when nothing more than this ever happens, it is understandable why the conference is easily forgotten.

The observation is frequently made that auxiliary per- sonnel and nursing students are the ones who are genuinely cnthusiastic about the conference aspect of team nursing. Why shouldn’t this be so? For them it can be a learning situation, a place where their contributions are recognized and where they are made to feel important. It may help stu- dents to feel that they are a contributing part of the small

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work group. They may even, if lucky, begin to feel that they belong - a feeling often unobtainable throughout much of their student experience, when they are transients on a unit, responsible to an instructor who is also not an integral part not occur until the last year of their program, and for many students it may never occur.

of the work group. This “belonging” experience usually does When a student is the team leader she usually has the help

and support of an instructor and is motivated for numerous reasons to lead a productive conference. But when this same student becomes a staff nurse, who guides and supports her? Where does the staff nurse obtain know-how in produo tive group conference techniques? From whom does she gain support in a situation where she should “set the tone, maintain group control, be sensitive to members’ needs, guide the planning and evaluation of care, do incidental teaching,” and perform other “shoulds” ad infinitum. Who recognizes her efforts or offers helpful suggestions? Fre- quently, no one. Yet she is expected to perform these func- tions for team members while many of her own needs re- main unmet. In addition, she can scarcely help but feel guilty about neglecting conferences since people about her assist in perpetuating the myth that the mere fact of holding a conference is evidence that the team is functioning well.

Assumption No. 3: A written nursing care plan is developed as a means of helping the team members give effective in- dividualized care.

One product that is usually expected of the conference is a written patient care plan transcribed neatly under two succinct headings - “Problems” and “Approaches.” The

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belief is held that a Rand nursing care form showing a large number of items under these headings with some sort of statement under each item is evidence of good nursing care and productive conference time. Careful examination of the problems, however, usually shows that they are the nurses’ problems and not necessarily those of the patient and that the statements steadfastly remain as originally writ- ten until the patient’s discharge. It sometimes seems that the plan is regarded as an end in itself, not the means to an end.

Attempting to individualize a nursing care plan and at the same time fit it into this Procrustean bed of “problems” and “approaches” in six or more lines can become a wearisome and rote task. But again, who helps the team leader in guiding the group toward thinking about a nursing plan of care as well as about methods of implementing the medical plan of care, which are often what the “approaches” amount to? It would seem that those at the heart of nursing practice obtain the least help of all in attempting to improve their practice.

Assumption No. 4: Nonprofessional workers receive close help trnd guidance from a “professional” person.

In other words, the team method of assignment enhances supervision. But where has the staff nurse learned the prin- ciples of supervision? Where has she learned to work as leader of a small group? An even more basic question: If she is a recent graduate, has she learned to work with groups of patients, or has her experience been only in the hallowed one-to-one relationship? These abilities, it would seem, are assumed to accrue by experience and by observation of and help from her role model in supervision - the head nurse.

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Assumption No. 5: The head nurse has more time to curry out her own functions.

This assumption implies that the head nurse will be spending more time with patients and will have more time to guide, teach, and evaluate personnel, to spend with physicians, to attend meetings, to coordinate activities with other depart- ments, to plan referrals, and so on. The method of decentra- lization of authority, which delegates many traditional activi- ties of the head nurse to the team leader, does indeed give the head nurse additional freedom. What does she do with it? Has she been prepared at all for the broader responsibili- ties and functions of head nursing?

Certainly she was not prepared in her basic nursing pro- gram, for diploma, associate degree, and baccalaureate degree programs all purport to graduate students who are ready only for first-level positions. If the graduate of a diploma or an associate degree program decides, after a period of time, to obtain a baccalaureate degree as preparation for head nursing, she will find that no matter what her experience, the bacca- laureate degree now means only basic preparation, which does not include the specialty of administration. The nurse possessed of this basic preparation will certainly not find comfort in pursuing masters degree preparation for head nursing either. With a masters degree, she will find herself propelled rapidly into higher supervisory positions or, should she elect to remain in head nursing (against all advice of her colleagues), she will seldom find her remuneration differ- ent from that of fellow head nurses with but a fraction of her background.

A logical site for staff development, the in-service pro- gram of the employing hospital, is seldom geared toward developing head nurses or for assisting head nurses on the

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job. Indeed, in too many instances, inservice education could more aptly be called “Orientation, Nurse-Aide Training, and Incidental Demonstrations of New Equipment to Registered Nurses.” Moreover, a head nurse’s encouragement of excel- lence in nursing within her unit too often goes without nursing administration’s commendation, and the infrequent approval of her other authority, the physician, often comes because of her staff‘s “efficiency” in implementing medical orders.

An unfortunate aspect of this whole cycle is that many head nurses actually have a fair degree of latitude, were they prepared to use it, in developing their units, and more often than not have greater influence on staff relationships and patient care than do supervisors, who frequently tread a no- man’s-land of poorly defined responsibilties.

SOME IMPLICATIONS FOR ADMINISTRATORS

A central theme emerging from an examination of these five assumptions is that the registered nurse in too many hospitals, is the person to whom the least support and recog- nition is given. Auxiliary personnel frequently receive more attention from administration than does the nurse, who is expected to be self-directed, knowledgeable, composed, and cxemplary throughout days of dealing with frustrating and anxiety-producing situations. It is too frequently assumed that head nurses and staff nurses not only are competent in their own ministration and administration of nursing care but are also skilled in working with groups of people who may be widely divergent in background, preparation, and motivation. Again, the question must be posed, “Where and how do they learn to do this?”

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The two obvious places where nurses can learn these skills are in the preparatory institutions and in the employing institutions. A description of how they learn is more involved, since the methods employed are widely divergent.

Many schools of nursing have made and are making genu- ine efforts at incorporating within their programs realistic experiences which will furnish the student with positive know- ledge upon which to draw when she becomes a team leader. (I believe that many of our current educational practices need a fresh review in terms of what the new staff nurse’s responsibilties will be, but consideration of this subject is outside the scope of this article.)

Within the employing institutions, staff development is the responsibility of total administration. The inservice de- partment is usually singled out for its adequacy or inadequacy in providing staff opportunities to learn and grow on the job, but its programs and activities usually are only a re- flection of the administration’s philosophy. Inservice edu- cators are too often faced with challenges which they have neither the experience nor the training to cope with and are left to function by themselves with a dozen or so charges from administration, but with little support or constructive guidance.

In many localities, hospital inservice people have started to meet together on an informal basis to discuss common problems. Although the moral support they give each other may be substantial, they deserve more help than this, in- cluding the stimulus of ideas from outside groups such as general educators, nursing school educators, and industrial and business persons with experience in ongoing training programs.

It should go without saying that inservice educators need

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fully as much academic education and service experience as do preservice educators. Certainly the graduate nurse em- ployee has the right to expect guidance from qualified per- sons in both administration and inservice, including persons with ability to help her in the areas of organization, group leadership, personnel relations, and basic , administration principles, all of which are incorporated in team nursing.

Guidance in these areas can be carried out in several ways, notably by example. Perhaps one of the better of the planned methods is to have group classes at a time early in the staff nurse’s employment, with follow-up guidance on the nursing unit. The classes should be held at a time when work pressures do not impinge upon the participants’ thought processes. There should be outside reading assignments as well as practical testing of theories in work with personnel and patients. The class discussion leader should serve as a role-model - lecturing about group discussion techniques leaves much to be desired! Role playing and socio-drama can profitably be used, and when actual and recent incidents are used for the latter, the ensuing discussions can become lively and helpful. When each member becomes personally involved, such classes can be true learning periods.

During and after the classes, individual help in the actual situation is essential, but such help should not be limited to these weeks or to the ones immediately following the classes. Continuous and consistent guidance and support should come from each of the administrative and inservice persons. By frequently attending conferences and meetings when team reports are given, and by simply being with team members and team leaders at various times they can give an immeasu- rable boost to a person’s feeling of “They’re really interested in what I’m doing and in what we’re doing.” Many activities

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in which nursing personnel daily engage are anxiety-pro- ducing, and the support implied by another person’s presence cannot be overemphasized.

Since the conference is frequently such a stumbling-block for the team leader, the supervisor or inservice persons needs to be readily available for consultative assistance regarding this area, or perhaps she could serve as a role-model leader at appropriate times.

The involvement of personnel on all three shifts is a matter of planning. When total administration is committed to the philosophy of team nursing, this planning is not as difficult as it is often made out to be.

Because the head nurse is one of the most essential people in any plan of administering nursing services, she should be as involved as the team leaders and needs the same guid- ance and support. In addition, she needs a broader scope of knowledge about proficiency in leadership. A discussion of where and how she obtains this understanding and know-how is perhaps not relevant here, but I believe the question should be of concern to both service and education.

Enthusiasm about team nursing may lead to an unexpected, though not unusual, occurrence. Staff members may become wrapped up in their own meetings and forget for a time that the hospital nursing group is itself only a part, albeit a sizable part, of the larger health and medical team. The nursing group on a unit needs to meet together to plan and evaluate nursing care, but this planning should be contributory to the larger plan which evolves from the patient’s need for care from several services. Genuine ward conferences with involvement of the physician and departmental personnel responsible for varying aspects of the patient’s care are cer- tainly preferable to continual and exclusive nursing meetings.

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This sharing of services and knowledge is not always easy to bring about, as Brown, among others, has pointed out. (2) It should not be lost sight of as an important goal, however.

As a more detailed suggestion, the use of the stereotyped “Problems and Approaches” columns on Rand nursing care plans needs evaluation. It may very well be that a group with ability in problem-solving regarding patient care will use such a form constructively. However, groups just beginning to look at care in this way could more profitably use a gener- ous, open space on the Rand entitled simply “Nursing Com- ments.” Suggestions, comments, and plans for care will be spontaneosuly written there when a group does not feel pres- sure to make sophisticated statements and when authority figures take the lead in writing down the often small but essential items which contribute to continuity of care. How much better to have the information that a patient does not want to be disturbed until just before breakfast, then to have a beautifully written statement about a long-range objective, but a disgruntled patient!

SUMMARY

The success of team nursing does not rest upon methods, but upon the provision to staff members of recognition, security, and a chance to experience a sense of accomplish- ment. Only when these basic needs are met will the staff members be free to help meet patients’ needs. Team nursing has become a wordfact in too many places because the in- terst has been upon the method and not upon an examination of the assumptions upon which it is based - an examination which shows that the staff members, and especially the regis- tered nurses, are often being expected to perform functions

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€or which they have not been prepared and with which they have not been helped while on the job.

It is nothing less than naive to believe, “That unit has team nursing; that is why the staff members work together so well and the patients receive such excellent care.” The truth is, rather, “The members of that staff believe that they are doing an important job; they feel secure, others recognize their efforts, there is opportunity to learn, they know they won’t be ‘let down’ when times are difficult - therefore they work as a team, and the patients benefit accordingly.”

References 1. Galbraith, John Kenneth, “The Age of the Wordfact,” The

Atlantic 206:87, September, 1960. 2. Brown, Esther Lucile, Newer Dimensions of Patient Care,

Part 11, New York: Ruusseil Sage Foundation, 1962.

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