1. Payne, Rosemary MSN, RN
  2. Steakley, Bruce BSN

Article Content

At the National Institutes of Health Clinical Center, nurse managers support clinical research, maintain research participant safety, and provide a therapeutic milieu. As part of an overall look at nursing care in this complex research facility, we implemented a clinical research nursing initiative. We created a committee to review all models of care, as well as nursing roles, in place throughout the Clinical Center. Diversity best describes what the committee found in its examination of the various inpatient nursing units, including short-stay units, day hospitals, procedure units, and medical-surgical environments. There was a recommendation for a consistent model of care to be utilized in all areas.

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In service to the complex needs of individuals and groups of patients, primary nursing was selected as our evidence-based practice model. The two central premises of the primary nursing model of care are relationship building and rapport. Successful relationship building requires repetitive positive interaction between the nurse and patient. The energy derived from this dynamic relationship results in rapport.


Nurse managers are striving to provide a therapeutic, safe, and engaged environment for their patients, whereas their decision making and efforts are undermined due to shorter lengths of stay, high readmission rates, patient complexity, heavy workloads, and suboptimal staffing and skill mix.1,21,2 Amidst this uncertainty, there's an opportunity for nurse managers to embrace primary nursing as a structure to support relationship-based care and patient-centered philosophies.


The Clinical Center has two psychiatric inpatient units (pediatric/adults) and one adult inpatient substance abuse unit on which a primary nursing model of care has been the standard for many years. This paved the way for other areas adopting the primary nursing model.


Case study

Safety, engagement, education, and empowerment of the psychiatric patient have been identified as important aspects of the psychiatric nurse's role.3,43,4 These concepts will be applied to our case study, Amanda.


Amanda is an 18-year-old female patient who graduated from high school a year ago. During her first year of high school, Amanda's mother died. She has been living in foster care ever since and moved four times in the last 3 years. Amanda was initially diagnosed with dysthymic disorder. During another admission, Amanda was diagnosed with bipolar disorder-not otherwise specified. On her most recent admission, Amanda was diagnosed with posttraumatic stress disorder. Each time Amanda has been admitted to your unit, she displays suicidal thoughts and behaviors, and impaired cognition. Staff members have also noted possible auditory hallucinations. Amanda has experienced abandonment and physical and mental abuse. She has explored various street drugs and misused prescription amphetamine/dextroamphetamine. Amanda has been admitted to your unit 10 times in the last 5 months, with 15 ED visits during the same period.


Your review of Amanda's medical record reveals six major areas of concern:


* during each of the 10 admissions, she had a different nurse (engagement and empowerment)


* nursing assessments didn't generate clear or precise problems, goals, nursing interventions, and outcomes during the admissions (safety, engagement, education, and empowerment)


* patient preferences weren't identified or addressed; the documentation didn't suggest deliberate strategies or interventions to empower the patient (empowerment)


* the record lacks an individualized or specialized care plan (safety, engagement, empowerment, and education)


* the record lacks documentation of therapeutic nursing interventions offered and the effectiveness of the interventions (safety, engagement, empowerment, and education)


* the record lacks specific patient education and goals related to the patient's problems and concerns (education).



In view of these deficiencies, it's impossible to judge the total overall quality of patient care that was provided to the patient.


Relationship building and rapport

Relationship building and rapport are natural events that should occur and evolve during each hospitalization. These are feasible expectations when a unit is structured and processes are in place to embody a form of primary nursing.


The literature suggests that rapport is conveyed by the nurse in mutual respect, accessibility, personal character, and use of critical thinking:3


* mutual respect-between the nurse and patient (engagement and empowerment)


* accessibility-the nurse is readily available to the patient, especially during crisis and escalation episodes; the patient senses the "presence" of the nurse (safety, engagement, empowerment, and education)


* personal character-the nurse is honest, authentic, consistent, and genuine (safety, engagement, empowerment, and education)


* critical thinking-the nurse applies critical thinking skills (safety, engagement, empowerment, and education)


-empathy while maintaining boundaries and a nonjudgmental attitude with the patient


-the use of self, based on listening and observing the patient's interactions with the nurse, others, and the environment


-flexibility in care delivery


-meeting the patient where he or she is


-addressing immediate and basic needs and building toward addressing complex problems.



Rapport as an outcome of relationship building is conveyed by the patient to the nurse in the following manner:


* mutual respect-the patient respects the nurse's role and the contributions that the nurse provides (engagement and empowerment)


* accessibility-the patient voluntarily seeks out the nurse before loss of control due to feelings of agitation, anxiety, suicidal thoughts, and acting on suicidal or other destructive behaviors (safety, engagement, empowerment, and education)


* personal character-the patient trusts the nurse and willingly communicates critical clinical/personal information (safety, engagement, empowerment, and education)


* critical thinking-the patient perceives that he or she isn't in this crisis alone; rather, the patient and the nurse are in a partnership with both parties agreeing on goals and desired outcomes, and working toward them (safety, engagement, empowerment, and education).



With implementation of a successful primary nursing care model driven by relationship building and rapport, favorable patient outcomes are possible.



The deliverables of a primary nursing model of care only begin with the opportunities for creating relationships and rapport. In addition to a more satisfying experience for the patient, there's a refractory experience for the nurse that leads directly to increased job satisfaction. At the Clinical Center, we assist patients to stay in research and thereby contribute meaningfully to the body of knowledge related to mental illness.


Consider the following recommendations:


1. Assign the same primary nurse to the patient during each admission. New patients with the likelihood for readmission, those with uncontrolled comorbidities, or those who may require higher levels of expertise should also be considered. This allows for ongoing reinforcement and strengthening of relationship building and rapport.


2. Before implementing a primary nursing model, review patient perception surveys and National Database of Nursing Quality Indicators(R) results to identify areas of opportunity to improve patient outcomes and the nursing practice environment.


3. Champion the documentation of robust and pertinent nursing care plans, with input from the patient. Nursing care plans should be considered fluid and dynamic documents personalized to the patient at each admission.


4. Develop a primary nursing model that consists of highly competent and compassionate nurses who are able to apply the concepts of relationship building and rapport into their evidence-based nursing practice.



Nurse managers are challenged with limited nursing resources (numbers, skill mix, and expertise). We make daily, sometimes hourly, adjustments in staffing resources in the attempt to the meet the ever-changing complexity and workload of the patient population and census. These adjustments are barriers to creating the ideal model for safe and therapeutic nursing care delivery. A second challenge is garnering staff buy-in.


In the future, we plan to explore integrating the concepts of safety, engagement, education, and empowerment within the clinical research nursing domains: clinical practice, human subjects protection, contributing to the science, care coordination and continuity, and study management.5 Our initial concept map-the circle of primary nursing-will guide our decision making and clinical practice. (See Figure 1.)

Figure 1:. The circl... - Click to enlarge in new windowFigure 1:. The circle of primary nursing

Partnership for positive outcomes

Better patient outcomes are achievable in an environment that's relationship based. A primary nursing model lends itself to this through the real partnership of the nurse and patient. It's helpful for each to know what to expect of the other when interacting and meeting mutually developed goals to maximize the benefit of a hospitalization, as well as potentially reduce the incidence of readmission.




1. Bjorkdahl A, Palmstierna T, Hansebo G. The bulldozer and the ballet dancer: aspects of nurses' caring approaches in acute psychiatric intensive care. J Psychiatr Ment Health Nurs. 2010;17(6):510-518. [Context Link]


2. Petrucci C, Marcucci G, Carpico A, Lancia L. Nursing care complexity in a psychiatric setting: results of an observational study. J Psychiatr Ment Health Nurs. 2014;21(1):79-86. [Context Link]


3. Delaney KR, Johnson ME. Metasynthesis of research on the role of psychiatric inpatient nurses: what is important to staff? J Am Psychiatr Nurses Assoc. 2014;20(2):125-137. [Context Link]


4. Thibeault CA, Trudeau K, d'Entremont M, Brown T. Understanding the milieu experiences of patients on an acute inpatient psychiatric unit. Arch Psychiatr Nurs. 2010;24(4):216-226. [Context Link]


5. National Institutes of Health Clinical Center. Building the foundation for clinical research nursing: domain of practice for the specialty of clinical research nursing. [Context Link]