During the planning process, the CNO of Banner Estrella Medical Center (BEMC) met with the President of the Arizona Board of RN/LPN Nursing and discussed the roles of RNs and LPNs. At the time, most of the hospitals in Banner Health and throughout Arizona were trying to eliminate the use of LPNs, rather than maximize their role in a team-based model.

The CNO also made sure to get buy-in from physicians, sitting down and hearing their concerns (which were primarily quality of care and communication). And she established a Physicians Advisory Board to ensure that physicians would be actively involved in the model development and implementation.

Since BEMC opened as a new hospital, the administrators had the benefit of hiring for all positions with the knowledge of the new care delivery model the hospital would use. The model was always discussed in interviews to ensure buy-in from the very beginning and to set expectations. And acceptance of the model was a key factor in hiring decisions of all staff, including physicians. In addition, hiring managers spent a lot of time in the interviewing process trying to find the right individuals to staff the team nursing unit (that is, individuals who are able to delegate and work in a team).

All their LPNs are IV certified. When BEMC first opened, they were able to hire LPNs who already had this certification, but moving forward, BEMC is working with the local community colleges to see if this can be added to the curriculum. In addition, BEMC is exploring ways to offer the IV certification themselves.

One challenge of the new model was ensuring that RNs delegated work appropriately to other members of their care teams. Since current RN programs do not teach delegation and supervision, an advanced practice nurse and director of med-surg came together and developed a series on training in delegation and supervision. They brought in the president of the Arizona State Board of Nursing to talk about the scope of work for the different roles of RN, LPN, and CNA. All members of the team (RNs, LPNs, CNAs) were included in these meetings on scope of practice and delegation/supervision. Including all team members helped foster a sense of camaraderie and teamwork.

At the beginning, BEMC also offered significant on-the-job support and training on delegation and teamwork. For the first months of operation, the nursing managers developed work processes where the team and manager checked in briefly every two hours in order to help build confidence and trust that delegated tasks were being completed effectively. Senior clinical managers also rounded regularly to provide additional support for delegation.

BEMC now staffs five full-time nurse educators for the full facility. Training for new staff has been formalized into a two-week long orientation process, during which the principles of Banner and the details of the Medical/Surgical Unit Team Nursing model are covered.

In addition, nursing students from local schools are now exposed to the model during clinical rotations.

Finally, BEMC has a very robust training and technical support team (which includes nurses as support staff) to help staff effectively use all the technology systems available in the hospital.

One existing medical/surgical unit in a Banner Desert Hospital has adopted the Medical/Surgical Unit Team Nursing model. BEMC provided them with support, including teaching curricula, and the hospital got the model up and running on the unit in four months.

A new Banner facility, Banner Gateway Medical Center, opened in September 2007 with the Medical/Surgical Unit Team Nursing model in place.

In addition, BEMC is piloting a team-based approach to care delivery in the emergency department with a team consisting of an RN, LPN, and ED Tech.

The success of Medical/Surgical Unit Team Nursing model requires hiring and training RNs and LPNs who were willing to work in a team environment where the ability to delegate well was critical. The model relies on open communication and trust among team members; therefore, it would be difficult to implement in an environment that is heavily reliant on traveler nurses or one with high nursing turnover.