Primary Nursing: A Methodological Theory

/ Guest Contributor
Contributors: Mia Haddad
and
Jacqueline Fawcett
(member of the Nursology.net Advisory Team)


This blog presents a proposal to categorize nursology practice delivery models as methodological theories. Such theories can be thought of as assertions about the how, when, and where of implementing a way of practicing nursology, although not about the why of practice.

Defining practice delivery models as methodological theories is valuable for both research and clinical practice. This approach allows for a structured framework for understanding how nursology models operate within different settings. By formalizing these models, we can improve the clarity in nursing education and practice. Doing so facilitates research about best practices and patient outcomes, guides healthcare institutions in implementing evidence-based nursology care structures, and improves interdisciplinary collaboration through clearly defined nursologists’ roles and responsibilities

I (JF) have identified five nursology practice delivery models (Fawcett, 2021a, 2021b)–total patient care, functional nursing, team nursing, primary nursing, and the attending nurse. I indicated in these publications that each practice delivery model should be connected to a nursology conceptual model.

Richman and Fawcett (2020) found that Manthey (2019) linked primary nursing with Watson’s Theory of Human Caring (2002), that Gross (2020) linked primary nursing with the Synergy Model (Curley, 2007), and that Webb and Pontin (1997) developed a primary nursing audit tool based on the Roper-Logan-Tierney Model of Nursing Based on Activities of Living (Roper et al., 2000).

Niemela, Poster, and Moreau (1992) initially viewed the attending nurse model within the context of Johnson’s Behavioral System Model (1990). Ditomassi (2012 )and Jones (2020) later linked the attending nurse model with Newman’s (1997) Theory of Health as Expanding Consciousness and Watson’s Theory of Human Caring (Watson & Foster, 2003).

In this blog, we (JF and MH) propose that it could be possible to not only connect each practice delivery model to a specific nursology conceptual model but also express the practice delivery model as a methodological theory. More specifically, a theory for any given nursology practice delivery model would incorporate defined concepts and the relationships between them (concept definitions and associations between concepts). In this blog, we are focusing on primary nursing as initially developed by Manthey (1980). Although we use the term, nursology, when referring to our discipline, we have maintained the term, primary nursing, to avoid any potential confusion about this practice delivery model.

Manthey later explained that the essence of this practice delivery model is the relationship between the nurse and the patient, referring to this perspective as relationship-based care (RBC). She explained that she regarded RBC “as a customization of Primary Nursing” (Manthey & Lewis-Hunstiger, 2006, p.7), the foundation of which is “a healthy work culture” (Manthey & Lewis-Hunstiger, 2006, p. 8). RBC requires the nurse to engage in critical thinking, creative thinking, and reflective thinking, which is best accomplished when the workplace organization supports and provides the necessary time for this type of thinking. RBC encompasses “3 key relationships: (1) the provider’s relationship with patients and families, (2) the provider’s relationship with self (self-awareness), and (3) the provider’s relationships with collaborative colleagues” (Cropley, 2012, p. 334). Cropley (2012) identified seven concepts of RBC:

  • patient and family
  • leadership
  • teamwork
  • professional practice
  • care delivery
  • resources
  • outcomes

Use of these concepts is a way to operationalize the primary nursing concepts of “responsibility, authority, and accountability in a decentralized organizational structure” (Koloroutis 2024, as cited in Cropley, 2012, p. 334). For the purposes of this blog, we regard RBC as the conceptual model that we are connecting to our proposed methodological theory of primary nursing.

The 10 concepts of primary nursing identified by Watts and O’Leary (1980) and 4 additional concepts comprise the methodological theory of primary nursing. Ten of these concepts (which Watts and O’Leary 1980, pp. 90-91) called the 5 A components and the 5 C components) of primary nursing are:

  • accountability
  • advocacy
  • assertiveness
  • authority
  • autonomy
  • collaboration
  • continuity
  • communication
  • commitment
  • coordination

Manthey (1980) also identified accountability as a concept and added this concept

  • one [nursologists]-one patient relationship.

We have added three other concepts to this methodological theory:

  • duration
  • clinical facility
  • health team members

The definitions of the concepts are:

  • one nurse-one patient relationship— A unique relationship intentionally established by one nurse in interaction with one patient (Manthey, 2019).
  • Accountability—”acceptance of the ultimate results of action taken” (Watts & O’Leary, 1980, p. 90)
  • Advocacy—”the process by which one pleads the case of another” ” (Watts & O’Leary, 1980, p. 90)
  • Assertiveness—”the indication of appropriate behavior or feeling” ” (Watts & O’Leary, 1980, p. 90)
  • Authority—the right to use power or control to influence or command others” ” (Watts & O’Leary, 1980, p. 90)
  • Autonomy—”the commitment to self-direction or initiation oi independent action” (Watts & O’Leary, 1980, p. 91)
  • Collaboration—”the sharing of insights, skills, knowledge, and/or resources of people” (Watts & O’Leary, 1980, p. 91)
  • Communication—”interaction or process in which information is interchanged” (Watts & O’Leary, 1980, p. 91)
  • Commitment—”support to a defined cause” (Watts & O’Leary, 1980, p. 91)
  • Continuity—”an uninterrupted process” (Watts & O’Leary, 1980, p. 91)
  • Coordination—“organized action” (Watts & O’Leary, 1980, p. 91)
  • One [nursologists]-One patient relationship—Each nursologist forms a partnership with one person known as a patient
  • Duration – The nurse-patient relationship extends for 24 a day for as many days as the patient requires care.
  • Clinical facility – The setting in which the nurse-patient relationship occurs
  • Health team members – The nurse and all others who the nurse involves in the care of the patient

Manthey’s (2019) discussion of primary nursing brings together some of these concepts. She wrote, “The [nursologists]-patient relationship is the essence of [nursology]. As with any relationship, it has a beginning, middle and end… . . The second foundation is professional accountability. This is the bedrock of a profession and follows both responsibility and authority. The nurse accepts responsibility by establishing a responsible relationship with the patient that is known within the unit. Based on the experience of establishing an intentionally responsible relationship (through which a [nursologists] becomes a professional) the primary [nursologists] comes to experience the legitimate decision-making role inherent in the relationship” (p. 2).

Building on Manthey’s foundational perspective, we propose that a more comprehensive statement of the association between all primary nursing concepts, which can be regarded at the methodological theory of primary nursing. This statement is: The one nursologist-one patient relationship exhibits accountability that extends for the duration of 24 hours every day during which the patient is in a clinical facility. The nursologist has a commitment to continuity of advocacy for the patient, doing so with assertiveness, authority, and autonomy, as well as collaboration and coordination with the healthcare team.

We propose that the empirical indicator can be an audit tool, similar to the tool developed by Webb and Pontin (1997), that measures the extent to which each of the 14 concepts of primary nursing is implemented in each nursologist-patient dyad in primary nursing practice.

Establishing primary nursing as a methodological theory provides a structured framework that can transform clinical practice, nursology education, and healthcare policy. By formally defining the core concepts and their interconnectedness, this model supports evidence-based decision-making, ensuring that nursologists’ care remains patient-centered, accountable, and continuous. The proposed audit tool serves as both a measurement and quality improvement mechanism, allowing healthcare institutions to assess the reliability of primary nursing implementation and identify areas for practice refinement.

Moreover, integrating this theory and RBC into nursology education and leadership training can empower nursologists with the skills necessary to navigate the complexities of modern healthcare settings. A theory-driven approach promotes professional autonomy, improves interdisciplinary collaboration, and reinforces nursologists’ authority in patient care decisions. Additionally, health policies that prioritize primary nursing should lead to improved staffing models, better nurse-patient ratios, and stronger workforce retention strategies, ultimately benefiting both patients and healthcare systems.

The methodological theory of primary nursing provides a structured approach to understanding and implementing this care model. Health policies should align with RBC, ensuring that the nursologist-patient relationship remains central to care delivery. By formalizing primary nursing as a theory, we can strengthen its application in education, research, and practice, ensuring high-quality, patient-centered care remains at the forefront of nursology.

References

Cropley, S. (2012). The relationship-based care model. Journal of Nursing Administration, 42 (6), 333-339. doi: 10.1097/NNA.0b013e31825738ed.

Curley, A. Q. (2007). Synergy: The unique relationship between nurses and patients. Sigma Theta International.

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

Fawcett, J. (2021a). Thoughts about nursing practice delivery models. Nursing Science Quarterly, 34(3), 328-330.
doi; 10.1177/08943184211010460journals.sagepub.com/home/nsq

Fawcett, J. (2021b). More thoughts about nursing practice delivery models. Nursing Science Quarterly, 34(4), 458-461.
doi: 10.1177/08943184211031584journals.sagepub.com/home/nsq

Fawcett, J., & Richman, K. (2020, December 8). Primary Care, Primary Nursology, and the Attending Nursologist: Connections to Nursology Conceptual Models and Theories. nursology.net. https://nursology.net/2020/12/08/primary-care-primary-nursology-and-the-attending-nursologist-connections-to-nursology-conceptual-models-and-theories/

Gross, A. Personal communication, October 30, 2020.

Johnson, D.E. (1990). The behavioral system model for nursing. In M. E. Parker (Ed.), Nursing theories in practice (pp. 23–32). National League for Nursing.

Jones, D. Personal communication, October 31, 2020.

Koloroutis. M. (2004). Relationship based care: A model for transforming practice. Creative Health Care Management.

Manthey, M. (1980). The practice of primary nursing. Blackwell.

Manthey, M. (2019). The practice of primary nursing. Theoretical framework and experience from the U.S. NSC Nursing, 4(1), 1-5. https://doi.org/10.32549/OPI-NSC-30

Manthey, M., & Lewis-Hunstiger, M. (2006). Relationship-based care: Customized primary nursing. Creative Nursing, 12(1), 4–9. https://doi.org/10.1891/1078-4535.12.1.4

Newman, M.A. (1997). Evolution of the theory of health as expanding consciousness. Nursing Science Quarterly, 10, 22–25. doi: 10.1177/089431849701000109

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. doi: 10.1111/j.1744-6171.1992.tb00123.x

Roper, N., Logan, E., & Tierney, A. J. (2000). The Roper-Logan-Tierney model of nursing based on activities of living. Churchill Livingstone.

Watson, J. (2002). Assessing and measuring caring in nursing and health sciences. Springer.

Watson J, & Foster R. (2003). The ATTENDING NURSE CARING MODEL: integrating theory, evidence and advanced caring-healing therapeutics for transforming professional practice. Journal of Clinical Nursing, 12(3), 360–365. https://doi.org/10.1046/j.1365-2702.2003.00774.x

Watts V. A., & O’Leary J. (1980). Primary nursing: description, analytical, and experimental research studies. The components of primary nursing. Nursing Dimensions, 7(Winter), 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. doi: 10.1111/j.1365-2702.1997.tb00333.x

About Mia Haddad

Mia Haddad, MSN, RN, CCRN, CWS, is an experienced nursing professional and the Nurse Director for an adult medical unit at Massachusetts General Hospital. Starting her career in 2011 at Parkland Medical Center, she later joined MGH in 2012, where she worked in various roles across the heart and medicine service lines. Mia holds a Master of Science in Nursing from UMass Boston and is currently pursuing a PhD in Nursing with a focus in health policy at UMass Boston. With extensive leadership experience, she played a vital role in opening new units during the COVID-19 pandemic and actively contributes to multiple hospital committees. Mia is also a certified wound specialist and Reiki practitioner, dedicated to enhancing both patient care and staff well-being.

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