1. Manthey, Marie MNA, RN

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Relationship-based practice is the new name for primary nursing. Originally created as way for staff nurses to accept responsibility for planning and managing the care of a small caseload of patients over time, hopefully from admission to discharge, this revolutionary (both then and now) care delivery system requires a level of competence, personal empowerment, and professionalism that continues to challenge nursing practice within the healthcare hospital environment.


Throughout the 1970s and 1980s, nursing departments throughout the United States converted from task-based team nursing care delivery systems to patient-focused primary nursing-type systems. The term primary nursing was never trademarked or copyrighted, so various meanings and definitions proliferated. Most people understood the concept well from seminars, articles, research, and practice.


For some, however, the issue of the authority of the bedside nurse posed an almost-insurmountable challenge. Rather than face the complicated transformation primary nursing required, these leaders relied on mechanical explanations that began to compromise the system. The most popular mechanical explanation was that this system required more registered nurses (RNs). Intuitively, it seemed logical, and those of us who were involved in the original development thought so for a period of time, as well. However, within a short time, experience, greater understanding, and common sense showed us that workloads did not change and, therefore, staffing need not change because of the system. At no time did I ever, in written or spoken words, suggest that primary nursing should, by itself, be used to justify a change in staffing level or skill mix. Nevertheless, many chief nurses recognized that the promise of patient-centered care could be used to upgrade their skill mix toward an all-RN staff and could be used to justify a richer level of nurses in the nurse-patient assignment ratios. The result was a belief that primary nursing required more RNs.


This left nursing vulnerable to the cost-cutting recommendations of major accounting/consulting firms. It was relatively easy for these firms to convince hospital boards of directors and administrators that millions of dollars could be saved (forever, not just this year) by reducing the RN ratio and adding lesser skilled staff to perform tasks that required little skill. When the number of RNs is based on a delivery system rather than patient acuity, it is easy for executives to mandate salary reductions by requiring delivery system change. These accounting/consultation firms made millions of dollars recommending reductions in RN ratios. One firm published a "study" showing how to reduce millions of dollars by converting RN positions to licensed practical nurse (LPN) positions and LPN to nursing assistant positions. Based on "funny-number data sets," these "savings" had nothing to do with the knowledge and skill levels of care required by their patient populations. The resulting RN lay-offs throughout the United States in the 1990s contributed significantly to the current crises in nurse staffing the nation is now experiencing.


The 1990s brought business-driven changes, such as mergers, acquisitions, the growth of shareholder-owned hospitals, and health maintenance organizations (HMOs) to healthcare. The workforce changed as generation Xers entered, baby-boomers retired, the 12-hour shift became more popular, and hospitals began importing more international nurses. These factors have resulted in highly unstable business-driven hospital cultures, where the concept of caring often seems out of place. Nevertheless, there is a now a rush to return to relationship-based practice, always the true essence of primary nursing.


Nursing departments today are finding ways to incorporate the principles of relationship-based care into daily practice and are using several terms for the care provider who is responsible for that relationship. Some call this person the care coordinator, others the RN (responsible nurse), the PRN (principal responsible nurse), the case manager, or the care manager. The name doesn't matter. What does matter is that all patients who need an RN, have an RN: an RN who has accepted responsibility for managing and coordinating patients' care in the hospital and do their discharge plans, an RN that patients, their families, the healthcare team, and the rest of the staff can identify as having the responsibility and authority for care planning. Thirty years after the onset of primary nursing, it is clear to the whole profession that professional nursing is not task based; if it isn't about a relationship, it isn't about nursing.


Too often, the vexing problems of scheduling logistics, bad assignment practices, and stubborn staffing inadequacies prevent us from giving patients relationship-based nursing care. We need to think, plan, and execute our way clear of these problems and into smoother patterns of resource acquisition and allocation: patterns that are consistent with our values and with our covenant with the public to provide humane, sensitive, and intelligent care. It can be done. It is being done in some places, sometimes. It must be done everywhere, all the time.


I want to close by describing the care a friend of mine received at a hospital here in Minneapolis. It may not be called primary nursing, but it is the absolutely the best kind of care anyone can receive: human, coordinated, and professional. Each nurse who interacted with my friend understood the definition of professional nursing as defined by Sister Madeline: a role where the nurse uses herself therapeutically in the relationship with the patient. 1


My friend was admitted with a diagnosis of chest pain. In the emergency room, several professionals applied electrocardiogram (EKG) leads, drew blood, and asked many questions. They frequently checked to make sure she was comfortable. Her EKG showed some changes during the few hours she was in the emergency department, the blood work was inconclusive, and she was transferred to a monitored intensive care unit for further evaluation. When the cardiologist examined her, he found some abdominal tenderness under her ribcage on the right side, and he decided to do an ultrasound to rule out cholecystitis. At 9 pm, seven hours after she had entered the emergency department, the ultrasound was done, with a positive finding. By 10 am the next morning, a Saturday, she was in the operating room having a laparoscopic cholecystectomy done, after which she spent a few hours in the recovery room before being transferred to the postoperative floor. She stayed there until she was discharged at 8 pm the following day.


Within 30 hours, my friend received care from the nursing staff on 5 units, was evaluated/treated by 4 physician specialists (not counting radiologists, anesthesiologists, etc.), and had numerous diagnostic tests and an operative procedure. I was with her through most of these experiences. I saw the "timeless values" of nursing being administered to her in every 1 of the 5 units, not only by nurses but also often by physicians. In each unit, she was called by name, with attention being given to her preference about that. The nurses consistently established eye contact, spending a few minutes in a state of "intentional presence."


Even though her stay in each area was necessarily short, the same nurse delivered most of the hands-on care in each location. There were discussions in two different areas regarding some overall health issues not related to her current diagnosis. In each case, the nurse offered thoughtful advice about health promotion, diet, and exercise. They were not shy about discussing health promotion, even though they were working in short-term high-tech settings. As she moved from one area to another, she was often part of the "hand-over" report, and it was clear that the data transmitted included information about her personal individuality.


Although my friend experienced high-tech care in a short time frame, it absolutely reflected the kind of values some might consider old-fashioned or no longer realistic. Each nurse conveyed an attitude of caring about her as an individual. It was obvious that the nurses were skilled and competent and that they know nursing is primarily about caring human relationships. This is a hospital that has been in the throes of managed care, mergers, and cutbacks for more than 15 years. Turnover has marked the top of the nursing department. Yet each chief nurse officer has shared basically similar values, reinforcing the importance of a relationship-based practice and supporting a theoretic framework based on the concept of caring.


Relationship-based practice is the responsibility of each individual practitioner. The culture of a department can support that or challenge it; however, it is a value to be owned by an individual nurse. As the system has changed from a charitable focus to a financial focus, it has become more and more challenging for the nursing profession to deliver relationship-based care. However, every time I consider how hard it is to keep the "timeless values" of nursing within sight of current practice, I remember the message of Victor Frankl in Man's Search for Meaning: that no matter how oppressive a system is, no one can destroy each person's right to define the meaning of his or her own life. 2 To me, that translates to this: regardless of how high-tech, short-term, or financially driven the health system becomes, no one can tell nurses they cannot practice within a conceptual framework of "intentional presence in a therapeutic relationship with the patient," where the outcome is competent care that is oriented toward empowering patients to accept responsibility for living their lives with maximum health.




1. Vaillot Sister MC. Existentialism: a philosophy of commitment. Am J Nurs. 1966; 66:38. [Context Link]


2. Frankl VE. Man's Search for Meaning. Boston: Beacon Press; 1962. [Context Link]

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Guest Editorial