Contributor (with Jacqueline Fawcett): Katherine Richman

This blog is meant as a follow up to Christine Platt’s (2020) blog, “A Nurse Practitioner’s Perspectives on Theory in Practice.” Ms. Platt’s mention of primary care led us to recall primary nursing. Primary care refers to the type of care offered by nursologists, typically nursologists who hold graduate degrees and who are considered nursologist practitioners (NPs), such as adult and gerontological NPs, family NPs, and psychiatric-mental health NPs.

Primary Nursology

Primary nursing, which we call primary nursology, refers to the way in which nursologists offer care. It is a care delivery model that was introduced in the 1960s, and is characterized by “accountability, advocacy, assertiveness, authority, autonomy, collaboration, continuity, communication, commitment, and coordination” (Watts & O’Leary, 1980, p. 90). In particular, the primary nursologist is responsible for one or more patients for the entire duration of hospitalization or other clinical setting. Tiedeman and Lookinland (2004) explained:

Each patient is assigned a specific primary [nursologist] based on patient needs and the [nursologist’s] abilities. The primary [nursologist] assumes 24-hour responsibility and accountability for assigned patients for the duration of their hospital [or other clinical setting] stay and has the responsibility and authority to assess, plan, organize, implement, coordinate, and evaluate care in collaboration with the patients and their families. The primary [nursologist] decides how care should be administered and personally administers it whenever possible. When the primary [nursologist] is not available to provide care, responsibility is delegated to an associate [nursologist] who cares for the patients following the care plans developed by the primary [nursologist] (p. 295).

A mid-October 2020 search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL Complete) revealed that discussions of primary nursing (the search term used) rarely mention any conceptual or theoretical basis. An exception is Webb and Pontin’s (1997) report, in which they described their use of the Roper-Logan-Tierney Model of Nursing Based on Activities of Living as the conceptual model on which they based development of a primary nursology care plan audit tool. The audit revealed that “although [nursologists] claim to use a [nursology] framework to structure their care, this is not evident in the documentation” (Webb & Poutin, 1997, p. 399). Another exception is at the Dana-Farber Cancer Institute in Boston, Massachusetts, where the Synergy Model is used as the conceptual basis for practice, coupled with primary nursing for delivery of nursing care (A. Gross, personal communication, October 30, 2020).

A Reflection on Primary “Nursology”

I (KR) was fortunate to begin my professional career, in the mid-1980s, as a primary nurse on a closed adult psychiatric unit. We were a group of hospital diploma and community college graduates, primarily, mentored by a trio of ultra-competent, assertive, and kind nursing leaders. Our practice was not modeled on any specific conceptual framework. Instead, it was modeled on a commitment to strong interdisciplinary leadership and excellent, compassionate care. Like the attending nurses described by Niemela and colleagues (1992) at the UCLA Neuropsychiatric Institute and Hospital, we coordinated and oversaw the care of our primary patients from admission to discharge. We were, in effect, their case managers; in an era when stays were measured in weeks and even months, we convened cross-disciplinary staff conferences and followed up with multidisciplinary treatment plans. We carved out time in every shift to sit and talk with our patients. Each patient was assigned both a primary nurse and an associate nurse. Both roles were filled by the full-time staff nurses.

Our practice model was, to echo Niemela et al. (1992), a “cost-effective, clinically productive, and professionally attractive role,” in our case for clinicians with entry-level nursing credentials (p. 5). The clinical specialist who headed our team eventually pursued her doctorate, though tragically she did not live to complete her degree. Inspired by her memory and by her enduring example, I’m now pursuing my own nursing doctorate.

The Attending Nursologist

After recalling primary nursology, we recalled the attending nurse, to whom we refer as the attending nursologist. The attending nursologist is a variant of primary nursology. A very special feature of the attending nursologist is the explicit link to Johnson’s Behavioral System Model.

The idea of the attending nursologist is a care delivery model developed and implemented at the University of California-Los Angeles (UCLA) Neuropsychiatric Institute and Hospital in the early 1990s (Dee & Poster, 1995; Moreau, Poster, & Niemela, 1993; Niemela, Poster, & Moreau, 1992; V. Dee, personal communication, October 17, 2020). Fawcett and DeSando-Medaya (2013) explained:

The major focus of [the attending nursologist’s] role is clinical case management. Role responsibilities include direct patient care; delegation and monitoring of selected aspects of [nursology] care; provision of leadership, consultation, and guidance to [nursologists]; and collaboration with [multiple discipline] team members. Moreau and colleagues (1993) reported that the [attending nursologist initiative] was well received by the [nursologists] and members of the [multidisciplinary] team. Moreover, attending [nursologists] reported an increase in job satisfaction and retention and a decrease in role conflict [Moreau et al. 1993]. Neimela and colleagues (1992) reported that the attending [nursologist initiative] increased general satisfaction and role clarity and decreased role tension for the [nursologists], and increased their communication with patients’ family members (p. 71).

Dr. Vivien Dee graciously replied to my (JF) query about her experiences with development and implementation of the attending nurse (nursologist) model of care delivery. She explained that the Dee and Poster (1995)

article was written to show the process taken by a chief nurse to bring about change in the workplace, moving from the Primary Nursing Model to the Attending Nurse Model for the delivery of nursing care. The attending nurse would be responsible for the nursing care of designated patients (from admission to discharge) 24/7, in contrast to the primary nurse (shift-based). The Attending Nurse must be a Clinical Nurse Specialist (Masters- prepared), responsible for self-scheduling, and has the authority to prescribe care based on the scope of practice for independent functions based on the California Nurse Practice Act. [The Dee and Poster] article addresses the phases of change using the Kanter’s Theory of Innovative Change, and the role of the executive nurse leader in creating the change. (V. Dee, personal communication, October 17, 2020)

Referring to the authors of the Niemela et al. (1992) and the Moreau et al. (1993) articles, Dr. Dee noted that Niemela “was the clinical nurse specialist – who assumed the role of the Attending Nurse, [and] Moreau was the nurse manager on the unit where the innovation took place. Poster was the Director of Education and Research”. (V. Dee, personal communication, October 17, 2020). Dee was the chief nurse (and the first PhD prepared nurse executive within the UC Hospital system of five hospitals) who implemented the attending nurse practice delivery model (V. Dee, personal communication, November 5, 2020).

Dr. Dee explained,

“The Attending [Nurse] Model was in place throughout my tenure at UCLA-Neuropsychiatric Institute and Hospital (NPI&H). I retired from UCLA-NPI&H [in] 2005. I have never looked back and have not kept up to date if the system is still in place. I think that the DNP today could very well serve as the Attending Nurse (similar to the Attending Physician role). But we need an executive nurse (CNE) with a DNP/PhD to fearlessly lead and create structures that allow for the full scope of practice for nurses with better patient outcomes.” (V. Dee, personal communication, October 17, 2020)

Ditomassi (2012) explained that the attending nurse practice delivery model also has been used by staff at the Massachusetts General Hospital (MGH) in Boston. “[A]ttending nurses function as clinical leaders, managing the care of patients on a single unit from admission to discharge. The attending nurse interacts with the inter-disciplinary team, the patient, and the family to foster continuity, responsiveness, quality, safety, effectiveness, and efficiency . . . And attending nurses make a commitment to work five eight-hour days to promote continuity and relationship-based care” (Ditomassi, 2012, p. 8). Specifically,

“The attending nurse:
• facilitates care with the entire healthcare team. Is a consistent contact for patients, families, and the healthcare team throughout the patient’s care
• identifies and resolves barriers to promote seamless hand-overs, inter-disciplinary collaboration, and efficient patient throughput
• coordinates meetings for timely, clinical decision making and optimal hand-overs across the continuum of care
• ensures that the team and process of care sustain continuous, caring relationships with patients and families that may begin before admission and continue after discharge
• develops a comprehensive patient-care assessment and plan using the principles
of relationship-based care
• communicates with patients and families around the plan of care, answers questions, teaches and coaches
• develops and revises patient-care goals with the clinical team daily
• organizes team huddles that include the attending nurse and physician, staff nurses, house staff, and other disciplines
• serves as a role model for inter-disciplinary problem-solving
• meets with families on a continuous basis regarding the plan of care, disposition, goals of treatment, palliative care, and end-of-life issues” (Ditomassi, 2012, p. 8).

The conceptual and theoretical perspectives used in conjunction with the attending nurse practice delivery model at MGH include, as Ditomassi (2012) and D. Jones (personal communication, October 31, 2020), who is a faculty member at Boston College William F. Connell School of Nursing and director of the Yvonne L Munn Center for Nursing Research at MGH (Ives Erickson, Jones, & Ditomassi, 2013), indicated, relationship-based care, as well as Newman’s Theory of Health as Expanding Consciousness and Watson’s Human Caring Theory, as well as an instrument used to measure Barrett’s Theory of Power as Knowing Participation in Change (D. Jones, personal communication, October 31, 2020).

Ditomassi (2012) mentioned that the attending nurse practice delivery model also was being used at New York University and Baptist Hospital of Miami, Florida. An early November 2020 search of the CINAHL Complete database, however, yielded no relevant literature.

We welcome readers to add what they know about and/or have experienced within primary nursing and/or attending nurse practice delivery models and to refer us to other published and anecdotal accounts of these contemporary approaches to the delivery of nursologists’ practice delivery activities.

References

Dee, V., & Poster, E.C. (1995). Applying Kanter’s theory of innovative change: The transition from a primary to attending model of nursing care delivery. Journal of the American Psychiatric Nurses Association, 1(4), 112–119. http://doi.org/ 10.1177/107839039500100403

Ditomassi, M. (2012, November 1). The attending nurse role. Caring Headlines [Patient Care Services newsletter], 8-9. Massachusetts General Hospital. https://www.mghpcs.org/caring/Assets/documents/issues/2012/November_1_2012.pdf

Fawcett, J., & DeSanto-Madeya, S. (2013). Contemporary nursing knowledge: Analysis and evaluation of conceptual models and theories (3rd ed.). F. A. Davis.

Ives Erickson, J., Jones, D., A., & Ditomassi, M. (2013). Fostering care at the bedside. Sigma Theta Tau.

Moreau, D., Poster, E.C., & Niemela, K. (1993). Implementing and evaluating an attending nurse model. Nursing Management, 24(6); 56–58, 60, 64.

Niemela, K., Poster, E.C., & Moreau, D. (1992). The attending nurse: A new role for the advanced clinician—Adolescent inpatient unit. Journal of Child and Adolescent Psychiatric and Mental Health Nursing, 5(3), 5–12. http://doi.org/ /10.1111/j.1744-6171.1992.tb00123.x

Tiedeman, M. E., & Lookinland, S. (2004). Traditional models of care delivery: What have be learned? Journal of Nursing Administration, 14(6), 291-297. https://doi.org/10.1097/00005110-200406000-00008

Watts, V., & O’Leary, J. (1980). The 10 components of primary nursing. Nursing Dimensions, 7(4), 90-95.

Webb, C., & Pontin, D. (1997). Evaluating the introduction of primary nursing: The use of a care plan audit. Journal of Clinical Nursing, 6(5), 395–401. https://doi.org/10.1111/j.1365-2702.1997.tb00333.x

About contributor Katherine Richman

Katherine is a first-year nursing PhD student at the University of Massachusetts Boston, focusing on health policy. She holds a BSN from the University of Illinois at Chicago and a PhD in theology from Boston College.