The practice of Primary Nursing. Theoretical framework and experience from the U.S.
Adjunct Faculty university of Minnesota School of Nursing., President Emeritus of Creative Health Care Management. E-mail: firstname.lastname@example.org
Primary Nursing is a delivery system designed for use by a nursing staff in an acute care hospital. The actual practice of Primary Nursing reflects the legacy value of one patient, one nurse. It rests on three foundations: 1) the nurse patient relationship 2) professional accountability and 3/the healing quality of compassion. A key to success of the system is the establishment of a responsibility relationship by the nurse with the patient/family. This unique relationship is the essence professional practice as it facilitates the healing quality of compassion recognized by Hildegard of Bingen, Sister Madeline Clemence Vaillot and others. It also provides a framework for maximum professional accountability.
A common source of confusion is staffing issues re. Primary Nursing. Neither more staff nor a different skill are needed because of Primary Nursing. If staff is adequate before Primary Nursing, it will be adequate for Primary Nursing.
Keywords: Primary Nursing; professional practice; nurse patient relationship; legacy values; compassion; healing; Hildegard of Bingen; Jean Watson; Nightingale; accountability; responsibility relationship
The theoretical framework for Primary nursing is as modern as the future and as old as the past. History tells us that there have always been…. ’Those to whom it is given to care for the sick’.
The development of modern nursing is linked to societal needs and values and it began, in the 19th century, spearheaded during the Crimean War by Florence Nightingale. Since then, there have been many changes in health and illness, as well as in the systems and institutions supporting and controlling care. Whether ancient or modern nursing, there is one undying immutable legacy truth: The essence of nursing is the relationship between the patient and the nurse.
Primary nursing is a care delivery system created as a way of organizing nursing staff based on a professional nurse patient relationship. The delivery system originated on a medical unit at the University of Minnesota and was first described in print in 1980. The book is titled the Practice of Primary Nursing .
Primary Nursing rests on three foundations; 1) the nurse patient relationship, 2) professional accountability and 3) the healing quality of compassion.
The nurse patient relationship is the essence of nursing. As with any relationship, it has a beginning, middle and end. It can theoretically be established by either the nurse or the patient…but, in hospital nursing it should usually be established by the nurse. It is a unique relationship in that, as Sister Madeline pointed out in an article published in 1966 , ……the essence of professional nursing is the therapeutic use of the nurse in a relationship with a patient. This only occurs when the relationship has been intentionally established by the nurse and is clear to the patient, their family, the physician, other health disciplines, as well as other nursing staff members involved in the care of the patient when the Primary Nurse is not present.
The second foundation is professional accountability. This is the bedrock of a profession and follows both responsibility and authority. The nurse accepts responsibility by establishing a responsibility relationship with the patient that is known within the unit. Based on the experience of establishing an intentionally responsible relationship (through which a nurse becomes a professional) the primary nurse comes to experience the legitimate decision-making role inherent in the relationship.
It is helpful (but not essential) to have an external theoretical framework as a guideline for the exercise of authority. After some years without using a theoretical framework, we ended up integrating Watson’s theory of caring  into the framework of Primary Nursing. The professional nurse exercises legitimate authority by deciding (with the involvement of the patient/family in the decision-making process) the amount, degree and kind of nursing care the patient will receive within the overall framework of the medical plan established by the responsible physician.
The third foundation is the ageless wisdom centered on the value of caring and compassion. Hildegard of Bingen speaks of the healing quality of compassion as manifested by light. Nightingale is known as The Lady with the Lamp” so called by the soldiers she helped heal in a hospital in Crimea … and Jean Watson has articulated a very sophisticated theory of Caring that recognizes the value of high quality technical competence used in administering ‘caring’ that empowers patients and helps transform an episode of illness into an experience of growth. The nurse’s role is pivotal in this process and Primary Nursing is the only delivery system and role that carries this ancient knowledge forward into the field of modern hospital nursing.
Primary nursing in the US has taken many twists and turns. On the negative side, it has often become confused with staffing issues, as well as skill mix issues. In truth, primary nursing can work in any setting with any staffing level and with any skill mix that is appropriate for that population of patients. It is about a relationship…not about the workload. On the positive side, primary nursing has brought professional practice into hospital nursing, and now at least, nurses know whether or not they are in a professional role.
It requires nurses who are willing to accept responsibility, a manager who is an effective leaders and able to develop rather than control their staff, and a Q7unit culture that supports healthy interpersonal relationships within the entire staff.
This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.
Competing interests statement
There are no competing interests for this study.
- Manthey, M., (1980) The Practice of Primary Nursing. Blackwell Scientific Inc.
- Clemence, M., (1966) Existentialism: A philosophy of commitment. American Journal of Nursing, 66(3), 500-508
- Watson, J., (2002) Assessing and measuring caring in nursing and health sciences. New York: Springer Publishing.