GROUP 4

PRIMARY NURSING –BY MURRAY

PRIMARY NURSING In the 1970s, primary nursing care moved the care of the patient from the team to
the individual caregiver. Primary nursing as a system of care provided for quality comprehensive patient
care and a framework for the development of professional practice among the nursing staff. Primary
nursing was a logical next step in nursing’s historic evolution. By definition, primary nursing is a
philosophy and structure that places responsibility and accountability for the planning, giving,
communicating, and evaluating of care for a group of patients in the hands of the primary nurse. Primary
nursing was intended to return the nurse to the bedside, thus improving the quality of care and
increasing the job satisfaction of the nursing staff.

Definitions related to primary nursing are:

• Primary nursing—the hospital unit organization and philosophy that places on the RN responsibility
and accountability for the planning, giving, communicating, and evaluating of care for a caseload of
patients.

• Primary care—the community contact for a patient seeking entrance to the health care system. He
or she may see a physician, nurse practitioner, dentist, and so on and have his or her care given in
the office or clinic or be referred to a hospital.

• Primary nurse—an RN, usually full time, who is assigned specific patients to whom he or she will
provide primary nursing care during their stay in the unit.

• Associate or secondary nurse—any nurse caring for patients whose primary nurse is off duty; he or
she provides total 8-hour care.

• Total care—the provision of all professional nursing care needed by the patient during an 8-hour
shift. This includes medications, treatments, hygienic and comfort measures, teaching, support,
charting, reporting, and changing the care plan if necessary.

The basic concepts of primary nursing include fixed, visible accountability of the nurse for the care of
assigned cases and the inclusion of the patient in his or her own care. The primary nurse is expected to
give total care, to establish therapeutic relationships, to plan for 24-hour continuity in nursing care
through a written nursing care plan, to communicate directly with other members of the health team,
and to plan for discharge. The patient’s participation is expected in the planning, implementing, and
evaluating of his or her own care. Perhaps the best aspect of primary nursing is the improved
communication provided by the one-to-one relationship between nurse and patient. Associate nurses
are involved in this method by caring for the patients in the absence of the primary nurse. Their
responsibilities include continuing the care initiated by the primary nurse and making necessary
modifications. Conceivably, the primary nurse for a group of patients may be an associate nurse for
other patients. The role played by the professional nurse is determined by the assignment of patients,
which is made by the front-line manager or head nurse. Primary nursing was adapted in organizations to
fit the staffing patterns and general nursing philosophy. Because of the need for a high percentage of
professional nurses, other modifications of the system were developed, such as modular nursing.
 PRIMARY NURSING –BY SULLIVAN

Conceptualized by Marie Manthey and implemented during the late 1960s after two decades of team
nursing, primary nursing (Figure 3-4) was designed to place the registered nurse back at the patient’s
bedside (Manthey, 1980). Decentralized decision making by staff nurses is the core principle of primary
nursing, with responsibility and authority for nursing care allocated to staff nurses at the bedside.
Primary nursing recognized that nursing was a knowledge-based professional practice, not just a task-
focused activity.

In primary nursing, the RN maintains a patient load of primary patients. A primary nurse designs,
implements, and is accountable for the nursing care of patients in the patient load for the duration of
the patient’s stay on the unit. Actual care is given by the primary nurse and/or associate nurses (other
RNs).

Primary nursing advanced the professional practice of nursing significantly because it provided:

● A knowledge-based practice model

● Decentralization of nursing care decisions, authority, and responsibility to the staff nurse

● 24-hour accountability for nursing care activities by one nurse

● Improved continuity and coordination of care

● Increased nurse, patient, and physician satisfaction.

Primary nursing also has some disadvantages, including:

● It requires excellent communication between the primary nurse and associate nurses.

● Primary nurses must be able to hold associate nurses accountable for implementing the nursing care
as prescribed.

● Because of transfers to different units, critically ill patients may have several primary care nurses,
disrupting the continuity of care inherent in the model.

● Staff nurses are neither compensated nor legally responsible for patient care outside their hours of
work.

● Associates may be unwilling to take direction from the primary nurse.

Although the concept of 24-hour accountability is worthwhile, it is a fallacy. When primary nursing was
first implemented, many organizations perceived that it required an all–RN staff. This practice was
viewed as not only expensive but also ineffective because many tasks could be done by less skilled
persons. As a result, many hospitals discontinued the use of primary nursing. Other hospitals
successfully implemented primary nursing by identifying one nurse who was assigned to coordinate care
and with whom the family and physician could communicate, and other nurses or unlicensed assistive
personnel assisted this nurse in providing care.

DIFFERENTIAT
ED PRACTICE-SULLIVAN

Differentiated Practice Differentiated practice is a method that maximizes nursing resources by focusing
on the structure of roles and functions of nurses according to their education, experience, and
competence. Differentiated practice is designed to identify distinct levels of nursing practice based on
defined abilities that are incorporated into job descriptions. In differentiated practice, the
responsibilities of RNs (mainly those with bachelor’s and associate degrees) differ according to the
competence and training associated with the two education levels as well as the nurses’ experience and
preferences. The scope of nursing practice and level of responsibility are specifically defined for each
level. Some organizations differentiate roles, responsibilities, and tasks for professional nurses, licensed
practical nurses, and unlicensed assistive personnel, which are incorporated into their respective job
descriptions.

DIFFERENTIATED PRACTICE-MURRAY

DIFFERENTIATED PRACTICE Differentiated practice, another model of job design, from the work of
Primm and Rotkovich, identified different levels of clinical expertise.34, 35 This perspective suggested
two levels of nursing practice: (1) the professional nurse level, a BSN-prepared nurse (with all the
responsibilities of the primary care nurse and consideration of the cost of care), and (2) the associate
nurse level, an associate-degree nurse who assists the professional nurse. The cost management
component of this model includes awareness of supply costs, fiscal implications of therapeutic
interventions, and flexible staffing to deal with manpower and caseload needs. This has been an ongoing
issue in nursing, as both BSN and AD nurses are professional nurses with similar responsibilities. With a
serious nursing shortage facing the nation, the distinction between levels of education may, of necessity,
become blurred.