Primary Nursing

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.[1] For the duration of a patients episode of care, the primary nurse accepts responsibility for administering
some and coordinating all aspects of the patients 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 patients 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 clients 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.[2]
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

RN makes decisions for

Decision-making occurs
over a single shift;
Decision-making

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

individual patients based on

over a single shift

their therapeutic

either by an RN caring

relationship, which is

for the patient or by a

sustained for the length of

charge nurse.

stay of the patient on the

unit.

Work allocation

Nursing assignments are

Nursing assignments are

Nursing assignments are

Nurse assignments are

and/or patient

task-based, nurses are

based on level of

largely patient-based,

patient-based to ensure

assignment

assigned to tasks rather

complexity and

with RN providing

continuity of care. An RN is

than patients.

commensurate level of

activities of care. Nursing

assigned to a patient and

expertise; focus is on

assignments may vary

remains that patients

tasks to be

by shift based on

primary nurse for as long as

accomplished;

geography and patient

the patient remains on the

assignments change

acuity, without supporting

unit (unless circumstances

based on patient acuity

continuity of care.

and work complexity.

Communication is

Communication

hierarchical; task

Communication is

completion is documented

hierarchical; the care

and communicated to the

provider reports to the

charge nurse; the charge

team leader; the team

nurse pulls information

leader reports to

together for all patients

physicians and/or other

and communicates with

health care team

other members of the

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.

health care team.

require that a new primary

nurse is assigned).

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.

Managers promote the

Nurse manager
Management of
the unit or
environment of
care

Managers function as
overseers, assuring that
tasks are accomplished.

nurse-patient relationship

supervises the team

Managers serve as a

and the professional role of

leader who is

resource and promote

the nurse. They influence

responsible for

nurses having a stronger

care by creating a healthy

supervising other staff in

role in care decisions.

work environment and

the delivery of care.

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 about primary nursing

Facts about primary nursing

Primary nursing can be implemented with the available staffit does not require
Primary nursing requires an all-RN staff.

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

The essence of the primary nurses role is the acceptance of responsibility, authority,

care.

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 patients care.
Teamwork is critical to the primary nursing care delivery system. It has been
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.

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.
Clinical staff report a 25% reduction in work redundancy due to day-to-day continuity

Complex scheduling requirements prohibit

continuity of the nurse-patient relationship
central to the primary nurse model.

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 patients 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.[3]:172

History
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 lookand 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.[4] 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.[5] 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.