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Why Primary Nursing has Everything to do with Professional Practice

By Janet Weaver, MSN, RN, NE-BC, Consultant at Creative Healthcare Management 

When I first heard Marie Manthey state, “Primary Nursing is the only care delivery system that nails professional practice,” I wanted to know more. At the time I’d just begun what was to become an intense interest, belief, and later a transference of information to care providers about this way of delivering care to those experiencing illness, a procedure/surgery, or wellness care.

When searching for clarity on what defines professional practice, I found a variety of definitions and statements. According to Larson (Magali Sarfatti Larson, The Rise of Professionalism: a Sociological Analysis, Berkeley, California: University of California Press, 1978, p.208) there is agreement on a number of characteristics possessed by a profession, which include having:

  1. A professional association
  2. Institutionalized training
  3. Licensing requirements
  4. Work autonomy
  5. Colleague control (peer evaluation)
  6. A code of ethics

I wondered which of these characteristics, if any, Primary Nursing had that other care delivery systems do not. The answer was clear: work autonomy.

Decision making by a Primary Nurse involves the RN making decisions for a patient based upon the therapeutic relationship that a nurse has established, which, in contrast to all other care delivery systems, is sustained for an entire episode of care, which may be 15 minutes or 15 weeks. This doesn’t mean the Primary Nurse is the only one responsible. Each nurse caring for the patient has responsibility to follow the plan of care established by the Primary Nurse, change it when necessary, and even to make decisions in the best interest of the patient (that may differ from the plan of care), using common sense and critical thinking skills. In all other care delivery systems, functional, total patient care, and team nursing, decisions are often made by a charge nurse or manager, and if the RN providing care makes decisions, there is no structure for decisions to be followed by subsequent RNs caring for the patient.

How Primary Nursing is Different

When the Primary Nurse states, “I will be responsible for you during your stay…,” these Primary Nurses report an internal shift in the perception of their role. One nurse stated, “I was overcome by the feeling, ‘I am responsible,’” which quickly translated to, “I MUST do my best.” When a Primary Nurse assumes responsibility, it is far more likely that he or she will develop a therapeutic relationship and adopt practices such as a five-minute, eye-to-eye conversation with each patient each day.  This type of behavior takes the nurse from a task-based focus to a relationship-based focus and provides the infrastructure for professional practice. 

Responsibility and Privilege of Primary Nursing

As I think about the internal shift that occurs when an RN embraces the responsibility and privilege of being a Primary Nurse, I find myself thinking back to my days at the bedside. Of course it makes sense that as a Primary Nurse I would be more intentional with everything I do, especially when it comes to establishing relationships with patients and families. Professional practice would naturally move me from task-based care to knowledge-based care; from fixing to healing; from a focus of only physical care to one of holistic care that includes the body, mind, and spirit; from decisions based solely on policies and procedures to using professional standards and current research to make decisions; and from rules, habits, and routines driving my practice to my critical thinking and innovation being the impetus. 

Being Decisive

As the professional Primary Nurse, my thinking may sound something like this: I have 12 hours and four patients, what will I do with my time? If I spend five minute eye-to-eye with each patient, this will guide my choices for what I do and when I do it, as I’ll know what is most important to my patients. When it’s time to pass medications I’ll move from previous task-based thinking that I have to administer all medications within 30 minutes of the designated time to using my education and critical thinking to balance what meds actually need to be delivered in this timing with what will best serve those I’m caring for. Primary Nursing means the staff nurse is empowered as a decision maker for the nursing care the patient receives.  

Nurses must decide what to do and what not to do, and it is okay to leave things undone when they are not the priority. We cannot do everything. When choosing to not do something, rationale must be provided. This is the job of a professional nurse.  

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As a clinical nurse, Janet connected with her patients and felt great compassion for them. As her career evolved and she moved into leadership roles, something she’s done for nearly 30 years, Janet brought that same sensitivity to her teams. As a consultant for CHCM, Janet’s areas of focus include Primary Nursing, orchestrating the implementation of Relationship-Based Care (RBC) and facilitating Re-Igniting the Spirit of Caring (RSC). jweaver@chcm.com

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