How to Avoid Team Nursing Problems, Conflicts and Issues

There has always been controversy regarding the best nursing care model in hospital settings. One of the main problems with the team nursing practice model is inadequate staffing, which causes many nurses to dislike the concept. Each team member must be qualified and competent to perform their assigned tasks because this type of nursing is more task-oriented.

In hospitals, teams usually consist of a RN, LPN, and CNA; rarely does it consists of all RNs. Members do not have to love or socialize with each other but they must have the ability to communicate and work together in a cohesive manner. The following tips will help RNs avoid team nursing conflicts, issues, and problems in an effort to deliver quality patient care (which is the number one priority).

Know and Respect Each Team Member

The team is as strong and functional as the leader. It is not a dictatorship; everyone must work together and recognize, with respect, each other's contribution to the goal, which is quality patient care. Every member is important regardless of their title and rank; if there are any problems or assignment conflicts, a team member should be allowed to voice their concerns. There are times when nurses feel overwhelmed with the responsibility of supervising members of the team but with effective communication, this should not be an issue.

A leader should be approachable and appreciative with an ability to resolve conflicts and deal with problems that may break the team down. Every few years, there is a consensus that bedside care should be provided by RNs only, that LPNs and/or CNAs should be eliminated in hospitals. This is not practical given the complex care our patients require; the RN has responsibilities away from the bedside that would be neglected if there were not others on the team to assist. Every member in team nursing is valuable.

Delegation

Team nursing requires proficiency in task delegation. In order to delegate, the RN must know the scope of practice of each team member, otherwise, it is frustrating to ask a member to perform a task only to realize, the person is not qualified or it conflicts with the institution's policy. The assignments should be such that the RN performs tasks that only he can do and delegate most others. However, I have never delegated a task I have not done before or never would, and that includes bedpans and incontinent care.

Some members dislike team nursing because they feel the assignments are not fair, i.e. having the sickest patients, or performing the most tasks. Issues occur when team members began to wonder, "If I am doing the most bedside care, what will the RN do". There is so much behind the scene work (such as admissions, discharges, and orders) for the RN that should not require an explanation but most people expect one anyway.

There are also issues with leaders who feel they should not have to explain their assignment decisions to team members. To avoid problems and conflicts, all assignments are reviewed and discussed with the team. Communication mistakes can cause team division and dissention, which is counteractive to the whole concept. That is the purpose of the initial team conference, especially for resolving team issues.

Team nursing will not work if the RN feels they are the only ones who can competently care for their patients; they must trust in others unless there is a reason for concern. If the nurse has a certain way of performing some tasks and someone performs it differently, as long as the outcome (and integrity) is the same, there should not be an issue.

I remember, as a new nurse, the problem of "letting go" because I was taught, "if you want something done right, do it yourself". That is the easiest way to burnout early in nursing. Delegation can be difficult to learn and takes practice to perfect, the key is always communication.

Communication

It is not necessary to follow team members around to check if they are performing their assignment if a team conference is held at the beginning and periodically throughout the shift. Since the RN is the quarterback, it is the duty of team members to keep him apprised of patients' condition and changes.

After report and initial rounds, I let my team members know which patients I want to monitor closely; we may develop a schedule on making routine rounds on all patients. If my LPN is administering treatments for the team, I want to know when a dressing is removed so I can observe the wound. If the CNA's assignment is performing vital signs, she will already know which measurements to report immediately. Effective communication is important in team nursing.

Depending on my assignment, I may want to give pain medications since I have to evaluate the effectiveness (and may have to notify the doctor); I do not want my patients waiting for the LPN who may be tied up with routine medications and treatments. However, if the LPN has to give analgesics, I want to know right away so I can follow up appropriately. Remember, in team nursing, communication is ongoing and reciprocal; the RN should also report their task results to the team, especially new orders and treatments.

Responsibility

In team nursing, the RN team leader is ultimately responsible for assuring quality patient care and treatments per nurse's and doctor's orders. Assignments may change as the team changes, i.e. admissions, discharges, and staff breaks. There should be a contingency plan, in case of, anything can happen; task-oriented assignments are not set in stone.

Although it is not necessary to follow team members as they perform their tasks, it is necessary to follow up in a timely manner. If a member becomes bogged down and cannot stop to report patient changes, it is incumbent upon the leader to seek out the member for the information and to assist if needed. The excuse of not receiving report of elevated blood pressures, temperatures, etc. is not valid; it does not release the RN from responsibility. The leader may even have to perform the assignment of others, such as repeat vital signs, especially if the doctor has to be notified.

The nurse is still responsible for assessment, evaluation, and implementation of the nursing care plan. He is required to assist with patient care despite delegation and assignments. If a patient is to be turned every hour or has to get out of bed as ordered, it is the leader's responsibility to assist if necessary. If the leader is seen socializing and not helping, there will be conflicts and problems within the team.

I have seen many CNAs or LPNs (even patients) injured attempting to perform tasks without asking for help because that was their assignment. One nurse had a 250-pound patient fall on her because she did not want to ask for assistance. Fortunately, the patient was not injured but she sustained minor back sprain. Conversely, I have seen patients develop major pneumonia and bedsores because the team did not work together to get them out of bed or turned.

Team Nursing and Change

Historically, nurses hate change, period. When hospitals and units change care models, there will be issues such as sabotage and complaints; there will be personality conflicts. Change should take place with the patients in mind and, as long as staffing is adequate, team nursing is here to stay. It is cost-effective because many tasks do not require the qualifications and educational background of RNs.

It is a waste to have RNs constantly at the bedside performing baths, feedings, and other tasks, which do not necessarily require a license. Nurses' roles and responsibilities are continuously evolving to one of care management, supervision, patient education, and patient advocating. After practicing both primary care and team nursing, there are instances when one works better than the other and that is a change nurses should be prepared for regardless of any problems, issues, or conflicts.