NR 446 Week 5 Stroke Unit Team Analysis Paper Example

Who Owns the Meal Tray? An Interprofessional Team Analysis of Dysphagia Care on a Stroke Unit

Student Name

College of Nursing, Chamberlain University

NR 446: Collaborative Healthcare

Instructor Name

Month Day, Year

Who Owns the Meal Tray? An Interprofessional Team Analysis of Dysphagia Care on a Stroke Unit

The Unit and Its Care Delivery Model

This analysis studies a composite 24-bed acute stroke unit in a regional hospital. Most patients are admitted within a day of an ischemic or hemorrhagic stroke, stay four to seven days, and leave for home, inpatient rehabilitation or a skilled nursing facility. About half have some degree of dysphagia on admission. The unit runs a team nursing model: on each shift, a registered nurse leads a team made up of a licensed practical nurse and a certified nursing assistant for eight patients. The registered nurse holds the assessment and the plan, the licensed practical nurse gives most oral medications and treatments, and the nursing assistant delivers hygiene, meal trays, feeding assistance and intake records.

The model matters to this analysis because team nursing splits a patient's care across three people by task. Primary nursing would give one registered nurse the whole patient, including meals; functional nursing would split the work further, by task across all patients. Under team nursing, the person who knows most about a patient's swallowing, the registered nurse, is usually not the person in the room when the patient eats.

Who Answers for What

Each discipline that touches a dysphagic patient during a day answers for something no one else can. The speech-language pathologist answers for the swallow evaluation and the diet texture and liquid consistency recommendation, including strategies such as a chin tuck or small sips. The physician or advanced practice provider answers for the diet order itself, which turns the recommendation into an instruction the kitchen will follow. The dietitian answers for whether the prescribed texture meets the patient's calorie, protein and fluid needs, and for supplements if it does not. Food and nutrition services answer for sending the right texture on the right tray to the right room. The registered nurse answers for the bedside swallow screen on admission, for assessing aspiration signs, for hydration and for the plan of care. The nursing assistant answers for positioning the patient, feeding or setting up the tray as the plan directs, and recording what was eaten. The pharmacist answers for whether medications can be crushed or must be changed to another form for a patient who cannot swallow tablets.

Written out this way, every step has an owner, and the team looks complete on paper. The Interprofessional Education Collaborative (2023) describes clear roles and responsibilities as one of the core competencies of collaborative practice, and by that standard the stroke unit's roles are clear. The problem appears only when the steps are joined.

The Seam: Intake Between the Tray and the Plan

The seam on this unit is intake. Every discipline acts on it and no discipline owns its result. The speech-language pathologist sets a safe texture but does not see the patient eat after the evaluation. The dietitian calculates needs but reviews intake records only at the scheduled follow-up, usually every three days. Food and nutrition services deliver the tray and collect it, but do not record how much was eaten. The nursing assistant records intake as a percentage of each meal, but on a team with eight patients, three of whom need feeding help at the same time, the percentage is often estimated at tray collection. The registered nurse reads the intake record if there is time, but under team nursing is rarely present at meals and does not see what the percentage means.

The result is that a patient on a pureed diet with thickened liquids can eat a quarter of three meals a day for three days, drinking almost nothing because thickened water is unappealing, and the problem surfaces only when the dietitian arrives on the fourth day or when a rising sodium and creatinine appear on the morning labs. A composite review of 40 dysphagic patients on the unit found that 17 had recorded intake below half of their meals on two or more consecutive days, and in 11 of those 17, no discipline had documented a response before day three. No one was negligent. Each person did what their role required. What was missing was an owner for the question of whether the patient was actually eating and drinking enough.

Kitson et al. (2010) argue that eating and drinking belong among the fundamentals of care, the basic needs that are easy to divide into tasks and hard to hold as a whole, and that the division of fundamental care among many workers is itself a risk. The stroke unit shows that risk in a concrete form: intake is measured, recorded and reviewed by different people at different times, so it is never interpreted by anyone in time to act.

Testing the Seam Against Another Model

Under primary nursing, the registered nurse assigned to the patient would plausibly see intake as part of her own assessment and act on a poor day sooner. But primary nursing is not coming to this unit; the staffing mix is set by the hospital, and the nursing assistant role is essential to feeding help. The comparison is useful for a different reason: it shows that the seam is not caused by any one person's attention but by the way team nursing places the registered nurse's judgment away from the meal. The fix therefore has to carry the observation from the room where the patient eats to the person who interprets it, within the model the unit actually runs.

A Recommendation a Staff Nurse Could Start

The recommendation is a two-part routine that fits inside team nursing and needs no new staff. First, after lunch each day, the nursing assistant tells the team leader the intake for every dysphagic patient on the team for breakfast and lunch, as a spoken number rather than a chart entry, at the standing 1330 team check-in the unit already holds. Second, any patient whose intake is below half of both meals, or whose fluid intake is below a set daily volume by 1400, is flagged by the registered nurse on the unit whiteboard and in the plan of care, and the registered nurse pages the dietitian that day rather than waiting for the scheduled follow-up. The registered nurse also checks whether the liquid consistency is the reason the patient is not drinking and asks the speech-language pathologist to reassess if so.

I could start this myself on my own team next week, since it only changes what my team says to me at a meeting that already happens. Making it unit-wide, and adding an intake flag to the electronic record that alerts the dietitian automatically, is a decision for the nurse manager and the interprofessional stroke committee, and I would bring the results of a month on my own team to that committee. Reeves et al. (2017) found that interventions to improve interprofessional collaboration, such as structured meetings and checklists, may improve some outcomes, though the evidence is limited, which is a reason to start small and measure rather than to promise more.

References

Interprofessional Education Collaborative. (2023). IPEC core competencies for interprofessional collaborative practice: Version 3.

Kitson, A., Conroy, T., Wengstrom, Y., Profetto-McGrath, J., & Robertson-Malt, S. (2010). Defining the fundamentals of care. International Journal of Nursing Practice, 16(4), 423-434. https://doi.org/10.1111/j.1440-172X.2010.01861.x

Reeves, S., Pelone, F., Harrison, R., Goldman, J., & Zwarenstein, M. (2017). Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, 2017(6), Article CD000072. https://doi.org/10.1002/14651858.CD000072.pub3