Jacque Cobb, RN, of St. Luke’s Clinic – Eastern Oregon Medical Associates

Team nursing: How rethinking the RN role can free up your practice

By Jacque Cobb, RN, a team nurse at St. Luke’s Clinic – Eastern Oregon Medical Associates in Baker City, OR. Eight years ago I joined Eastern Oregon Medical Associates (EOMA) as an RN to help with workflow and complement the existing staff nurse RN. Since then we’ve transitioned to a team nursing model and have been practicing this way ever since. I love the idea that our story and the steps we took might inspire others. I was hired at a time when our small practice was expanding and our docs had limited availability. We looked at what the docs on staff were doing and how we might shift tasks and roles to address this access problem. They were seeing patients that an RN could easily triage by doing an early assessment, with the docs briefly stepping in as needed. We shifted those tasks to the staff nurse, which was the first step in freeing up our docs to see the acute patients that RNs couldn’t treat. Getting access under control Similarly, some tasks the staff nurse was doing could be handled by the MAs or the LPNs on the team, so we shifted those—creating a scheduling template for the staff nurse. Some of our patients needed a lot of history added to their charts but the docs didn’t need to do that. So we added mono, strep, UTI, blood pressure checks, lead screenings for HeadStart, and new OB patients to that scheduling template. With access to the docs under control, we then faced limited access to the staff nurse. Once again we compared tasks with staff capabilities. The staff nurse was seeing many blood pressure patients (doing BP checks) in 15- or 30-minute slots. We began a weekly blood pressure clinic free of charge to patients. This not only streamlined our workflow, but patients liked it because they no longer had to pay for a visit. Because of cost concerns, our docs had telling patients about ways they could check their BP for free, but that info didn’t always get back to us. Our docs loved the clinic because BP is documented in our EHR, and it stays in-house. Flowering into teams Three years into our redesign, we started integrating our RNs into the team nurse role. Our team nurses provide care management and care coordination for complex chronically ill patients, and they’re a special breed. We learned over and over that just because you’re an RN doesn’t mean you have an aptitude to be a staff or team nurse. A team nurse has to be able to work within the practice flow, to prioritize tasks, and to look outside of a narrowly-prescribed role. Hiring the right person is important: A team nurse is someone who is efficient, has a calm temperament, and can multi-task and prioritize. With all we’d learned, we started hiring more nurses. Our clinic was split into two teams, with each having one RN, four medical assistants, two docs, and two mid-level providers. The docs worked with the nurses dedicated to their team. This flowering into teams was what helped us retain our nurses. Our job satisfaction went up when we were able to spread the practice demands across all providers. Key steps in our transition
  1. Get specific about what you’re doing. It’s critical to take time to document your daily routine so that you can see where and what is causing the current role to be difficult or stressful.
  2. Slow it down so you can move forward. This goes hand in hand with defining challenges, but it’s worth calling out in and of itself. If you don’t slow down you can’t take any steps forward. The time it takes to break down a task isn’t staggering and the benefit is well worth it.
  3. Strategize with your colleagues. When we were building up to the team nursing model, we did lots of PDSAs (plan-do-study-act cycles). It wasn’t just one person carrying a torch—the three of us looked for ways to try to help everyone.
  4. Shift tasks and roles. Breaking down the role and tasks was the foundation that enabled us to make better use of our collective staff expertise, capabilities, and knowledge. In order for our nurses to work to the top of their license and skillset, some of the work they were doing needed to be handed off.
  5. Engage in self-reflection. I believe strongly that it’s worth being thoughtful about one’s professional happiness: “Yes, this is the job for me,” or “No, I need to find another way to pursue my nursing interests.” We nurses have flexibility to look inward and examine our aptitudes, what works, what doesn’t work.
Our staff and leadership were open to implementing our suggestions once we had evaluated which changes could be helpful. I have earned the perspective I have because I’ve worked in various positions throughout the clinic, and the current role of team nurse continues to evolve. Over the last eight years it’s clear: Things are going great here in Baker City. This is part two of a two-part series on St. Luke’s: Part one is Jonet Shepherd’s story about their referral coordination program. Jacque Cobb, RN, is a member of the St. Luke’s Clinic – Eastern Oregon Medical Associates (EOMA) team in Baker City, OR. One of 30 clinics nationwide invited by the Robert Wood Johnson Foundation to participate in their best practices program, The Primary Care Team: Learning from Effective Ambulatory Practices (LEAP), EOMA was invited into LEAP as a result of their dramatic improvements in patient care. Ms. Cobb’s work at St. Luke’s Clinic–EOMA is prominently featured in the LEAP Team Guide.

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