The nurses wanted to remove bureaucracy and wanted every nurse to touch patients. After first piloting in a small area of the unit, the model spread to the rest of the organization.
"We got rid of a lot of the noise in the professional nurse's day," says Fuller. She notes that if organizations take out the busy work, broken systems, and other non-value-added activities, it gives nurses time to concentrate on patients. "So they have time to think and time to lead and time to do all those things," she says. "We've worked hard on developing a rich information environment and developing our technology."
For example, the hospital's electronic documentation system is simple and quick, unlike many such systems. "Documentation is no longer a big task for nurses. It's just a by-product of doing your own stuff," says Fuller.
Nurses practice in a team model that places RNs at the heart of care coordination and does away with much of the hierarchy of traditional nursing care. "Our old model was so hopelessly broken," says Fuller. "Med-surg is the backbone of acute care, but people were not satisfied. We wanted to get away from a manual care model to a more technology- and information- and team-driven model."
"We empowered nurses to make changes in the care model, and some physicians questioned why they were not asked to 'give permission,'" says Fuller. "We had to work with them to understand that nursing is a profession with autonomy and the days of micromanagement by MDs were over."
Nursing care is now organized by teams that care for a cohort of patients. The teams are generally three people who care for around 10 to 12 patients. Teams may include two RNs and an LPN; an RN, an LPN, and a tech; and so on. There is always an experienced nurse who can huddle with the team to discuss patient care.
Fuller says these self-organized, agile teams decide for themselves how to organize the work that needs to be done for their patients that day.
"Because acute care has a lot of variability with what a team will encounter, we want the team to decide how to take care of patients that day and organize their own patient care needs," says Fuller.
Fuller admits that, early on, the new model was a little chaotic, in part because it eliminated the charge nurse role. "At first doctors didn't like it because they were used to having charge nurses round with them," says Fuller. "Bedside nurses had to learn care coordination." Nurses now go to daily care conferences where they participate in the discussion about their patients. All nurses are now actively involved and understand the system of care from more than just a narrow nursing perspective, allowing them to interact with every member of the care team, from physicians to respiratory therapists.
"We did not have too many turf battles with physicians because as a community hospital, we have always worked closely together to care for patients," says Fuller. "Without charge nurses, we had to assure the physicians that the bedside nurse was knowledgeable about the patient and available when they presented for rounds."
One way Prairie Lakes facilitates communication between nurses and physicians is with walkie-talkies that nurses can use to alert each other when a physician arrives on the unit. For example, "a nurse will announce on the walkie 'Dr. X just got off the elevator' and all the nurses on the unit hear the message and can respond as needed."