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Originated in 1969 by staff nurses at the University of Minnesota, Primary Nursing is a system of nursing care delivery which emphasizes continuity of care and responsibility acceptance by having one registered nurse (RN), often teamed with a licensed practical nurse (LPN) and/or nursing assistant (NA), who together provide complete care for a group of patients throughout their stay in a hospital unit or department. For the duration of a patient's episode of care, the primary nurse accepts responsibility for administering some and coordinating all aspects of the patient's nursing care. When RNs supervise LPNs and NAs in the care of patients, costs associated with labor and other resources typically decrease while more attentive, well-coordinated care is provided for patients, increasing patient satisfaction and safety.
This is distinguished from the practice of team nursing, functional nursing, or total patient care, in that primary nursing focuses on the therapeutic relationship between a patient and a named nurse who assumes responsibility for a patient's plan of care for their length of stay in a particular area.
Marie Manthey, one of the originators of this care delivery system and the author of The Practice of Primary Nursing (2002), asserts that a nursing system can enhance and facilitate either professional or bureaucratic values as it either focuses on caring for people or tending to the needs of an organization. From The Practice of Primary Nursing, “Primary Nursing is a delivery system for nursing at the station level that facilitates professional nursing practice despite the bureaucratic nature of hospitals. The practice of any profession is based on an independent assessment of a client’s needs which determines the kind and amount of service to be rendered: services in bureaucracies are usually delivered according to routine pre-established procedures without sensitivity to variations in needs.”
A delivery system is a set of organizing principles that is used to deliver a product or service and generally consist of four elements: decision-making, work allocation, communication, and management.The following table illustrates the similarities and differences between the four most common nursing care delivery systems:
|Element||Functional nursing||Team nursing||Total patient care||Primary nursing|
|Decision-making||Decision-making occurs over a single shift; decisions usually made by nurse manager or charge nurse.||Decision-making occurs over a single shift; largely by team leader or nurse manager.||Decision-making occurs over a single shift—either by an RN caring for the patient or by a charge nurse.||RN makes decisions for individual patients based on their therapeutic relationship, which is sustained for the length of stay of the patient on the unit.|
|Work allocation and/or patient assignment||Nursing assignments are task-based, nurses are assigned to tasks rather than patients.||Nursing assignments are based on level of complexity and commensurate level of expertise; focus is on tasks to be accomplished; assignments change based on patient acuity and work complexity.||Nursing assignments are largely patient-based, with RN providing activities of care. Nursing assignments may vary by shift based on geography and patient acuity, without supporting continuity of care.||Nurse assignments are patient-based to ensure continuity of care. An RN is assigned to a patient and remains that patient's primary nurse for as long as the patient remains on the unit (unless circumstances require that a new primary nurse is assigned).|
|Communication||Communication is hierarchical; task completion is documented and communicated to the charge nurse; the charge nurse pulls information together for all patients and communicates with other members of the health care team.||Communication is hierarchical; the care provider reports to the team leader; the team leader reports to physicians and/or other health care team members.||Communication is direct. However, in some Total Patient Care systems, RNs may be required to communicate with physicians and other members of the health care team through a charge nurse.||Communication is direct. Patient information is solicited by the primary nurse who communicates directly and proactively with team members, physicians, and other colleagues. The primary nurse is responsible for integrating information and coordinating care.|
|Management of the unit or environment of care||Managers function as overseers, assuring that tasks are accomplished.||Nurse manager supervises the team leader who is responsible for supervising other staff in the delivery of care.||Managers serve as a resource and promote nurses having a stronger role in care decisions.||Managers promote the nurse-patient relationship and the professional role of the nurse. They influence care by creating a healthy work environment and empowering the staff to remove barriers to care.|
From the book Relationship-Based Care: A Model for Transforming Practice (2004), Mary Koloroutis, editor. Used by permission.
Myths and facts about primary nursing
|Myths about primary nursing||Facts about primary nursing|
|Primary nursing requires an all-RN staff.||Primary nursing can be implemented with the available staff—it does not require special staff, nor does it require an all-RN staff. Licensed practical nurses, nursing assistants, and other team members play vital roles in meeting the needs of the patient and his or her family.|
|The primary nurse does all of the bedside care.||The essence of the primary nurse's role is the acceptance of responsibility, authority, and accountability for decisions about patient care. It is not about the primary nurse “doing it all.”
It is simply not practical for the primary nurse to complete all aspects of care. Obvious barriers to singular care by a primary nurse include shortened length of patient stay; escalating patient acuity levels; complex, multifaceted care requirements, and the cyclical nursing shortage. If the primary nurse were doing all of the bedside care, he or she would not be able to assume responsibility for planning and coordinating the patient's care.
|Primary nursing eliminates teamwork. Everyone works individually and therefore is not aware of patients other than their own. In a primary nursing model, care providers do not help each other.||Teamwork is critical to the primary nursing care delivery system. It has been demonstrated that the best utilization of ancillary staff is in relationship with one RN—(at least within a given shift)—not assigned to help many. However, a general culture of “helpfulness” based on a shared commitment to all patients and team members is necessary to achieve consistently safe, quality care.
Primary nursing supports collaborative interdisciplinary practice through communication and coordination.
|Complex scheduling requirements prohibit continuity of the nurse-patient relationship central to the primary nurse model.||Clinical staff report a 25% reduction in work redundancy due to day-to-day continuity of care. They also report a perceived increase in productivity through more consistent co-worker assignments. The key to achieving these results is to find creative methods to schedule nurses with continuity of care as the priority. For example, if a patient's anticipated length of stay is three days, schedule nurses three consecutive days.|
From the book Relationship-Based Care: A Model for Transforming Practice (2004), Mary Koloroutis, editor. Used by permission.:172
Marie Manthey tells this story about the origins of primary nursing in the book Relationship-Based Care: A Model for Transforming Practice:
“Primary Nursing was implemented in 1969 on Unit 32 at the University of Minnesota Hospital. This radical change in care delivery came about when a colleague, Pat Robertson (nursing supervisor) and I (assistant director of nursing) held an evening meeting with nursing staff and leaders at [my] home. This was an unprecedented and radical action—to invite staff nurses and leaders to come together to figure out how to improve patient care and the work environment itself. The nurses told stories about attempts to implement [care delivery systems like] Primary Nursing elsewhere in the United States, and we discussed how it could happen in our organization. Our message to the staff that night was that they have the ability to influence their own practice and how it will look—and step one was that it was okay for them to make patient assignments.” (p. 170)
The first seminar presenting primary nursing to the nursing community took place in 1970, and the first article, "Primary nursing: a return to the concept of 'my nurse' and 'my patient',” co-authored by Marie Manthey, Karen Ciske, Patricia Robertson, and Isabel Harris was published in January 1970 in the journal Nursing Forum. A second article, "A Dialogue on Primary Nursing," written by Marie Manthey and Marlene Kramer, was published in the journal Nursing Forum in October 1970. Throughout the 1970s, interest and development were steady, but never well-organized; however, several hospitals quickly realized the benefits of a primary nursing care delivery system to patients and nurses. The nursing staffs at Boston Beth Israel led by Joyce Clifford and Evanston Hospital led by June Werner were early adopters of primary nursing and were recognized for their outstanding work in fully implementing this professional nursing model.
- Manthey, Marie (2002). The Practice of Primary Nursing. Minneapolis, MN: Creative Health Care Management. p. 1. ISBN 9781886624177.
- Manthey, Marie; Ciske, K.; Robertson, P.; Harris, I. (1970). "Primary nursing: A return to the concept of "my nurse" and "my patient". Nursing Forum. 9 (1): 65–84. doi:10.1111/j.1744-6198.1970.tb00442.x.
- Manthey, Marie; Marlene Kramer (1970). "A dialogue on primary nursing". Nursing Forum. 9 (4): 356–379. doi:10.1111/j.1744-6198.1970.tb01048.x.