Primary Nursing

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FEBRUARY 1986, VOL. 43, NO 2

Primary Nursing ADAPTINGTHE CONCEPT FOR OR NURSES Kathleen A. Pattison, RN; Wanda J. Nelson, RN

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ociety is beginning to recognize the need to balance high-tech with high-touch described by John Naisbitt.l For nurses who practice in the increasingly technological environment of a hospital, attaining the balance is difficult. Some nurses have implemented primary nursing in an effort to provide high-touch and comprehensive, contiguous care to individual patients. Because perioperative nurses specialize in nursing care surrounded by high-tech, we believe they should be part of a primary nursing

team. Development and implementation of primary nursing between OR nurses and nurses on medicalsurgical units cannot be done independently; the two must be integrated to achieve continuity of

Kalhleen A. Pattison, RN,MS, CCRN, is a patient care coordinatorfor La Crosse (Wis) Lutheran Hospital. She earned her BSN from Eterbo College and her MS in community health education from the University of Wkconsiq both in La Crosse.

patient care and maintain effective communication. Primary nursing requires decentralized decision making. The concept supports the responsibility, accountability, and authority of the individual professional nurse, while supporting variations of primary nursing practice to accommodate flexibility in patient assignments, staffing, and communication? As early as 1970, the primary nurse was described as having the total, pervasive responsibility for planning and directing a patient’s care for 24 hours a day as long as hehhe is hospitalized? Subsequent definitions of nursing and primary nursing have provided only a basic framework for a primary nursing model in the operating room; implementation of this concept for perioperative

Wanda J. Nelson RN, BSN is the perioperative educator at La Crosse Lutheran HospitaL She earned her BSNfrom Eterbo College, La Crosse, Wk

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patient admitted --+

to hospital

assignment of primary nurse

-

transferred

patient returned to

to

primary nurse

patient

patient discharged

Fig 1. Time Line relating patient’s hospital stay and nursing responsibility.

n u m has received little attention in the nursing literature. This paper describes how the nursing staff of one hospital implemented primary nursing to include perioperative nurses.

Problem Defined

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hen the nursing department at La Crosse (Wis)Lutheran Hospital was reorganized into a decentralized management system, a clinical patient services division was formed to include specialty services. The perioperative nurses and other nursing services that provide direct nursing care in specific therapeutic, diagnostic, and consultativesituations were grouped together and included: intravenous therapy, metabolic support, infection control surveillance, and critical care special procedures. When the nursing department formulated a plan for primary nursing and presented it to the division, it did not address operating room nurses or other specialty service professionals. Because we believe

an important interface exists between the nurses on the surgical unit and perioperative nurses, we sought to include perioperative n u m in the plan. The interface can be visualized by picturing a time line relating the surgical patient to the nursing responsibility and the “gray area” of time not covered by the primary nurse’s responsibility (Fig 1). When the patient is admitted to the nursing unit, a primary nurse assignment is made and a care plan established. As the scheduled time for surgery approaches, nurses from the nursing unit and the preoperative area communicate pertinent information about the patient care plan. At that time, the primary nurse’s plan of care is superceded by the perioperative plan of care. As the primary nurse relinquishes control and responsibility for the patient’s plan of care, he/she does not develop or direct care again until after the immediate postoperative period. As a result, authority, responsibility, accountability, and continuity are no longer maintained by the primary nurse. Recognizing this gap in continuity, we saw the need to define primary nursing in the clinical 495

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services division as it interfaces with medicalsurgical areas. We chose to begin by titling the nurse who assumes responsibility, accountability, and authority during this “special care phase” the primary support nurse.

Primary support Nurse Defined

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he term p r i m l y support nurse was chosen because he/she has full responsibility and accountability for development and implementation of an individualized care plan and carries out the primary nurse role. Because the scope of that care is limited by time and procedures, we thought the term p r i m l y nurse was inappropriate. Also, the new name defines the relationship between the primary nurse and the perioperative nurse: the perioperative nurse supports the primary nurse role by initiating a plan at a time, or in a situation, that cannot be accountable to the primary nurse. The titleprimry support nurse identifiesthe role and responsibilities of the nurse in special care areas. Implementation of the perioperative primary support nurse role provides continuity of care in a therapeutic and safe manner when the primary nurse is not able to direct patient care. Communication between primary nurse and primary support nurse must occur before and after nursing intervention. This communication is crucial and must take place through established oral and/or written methods. The primary support nurse cares for the patient during special procedures that are part of the medical plan but are not done on the medicalsurgical unit. The primary support nurse functions as the patient’s advocate at a time when the patient may not be in control of the situation. The functions of the perioperative primary support nurse follow the nursing process framework.

Functions

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he perioperative primary support nurse takes charge of the patient in the immediate preoperative period and functions as the

circulator during surgery. The nurse assesses the patient’s status preoperatively either the day before surgery, in the preoperative care unit, or in the operating room suite. The OR nurse identifies immediate patient care goals and plans nursing interventions to meet those goals. In writing a care plan, the perioperative nurse considers surgical intervention and includes preparation of the operating room and necessary supplies and equipment. He/she uses the problemsolving approach in meeting the patient’s needs in the operating room and implements the care plan during anesthesia and surgery. The nurse demonstrates an ability to guide and direct health care professionals in using the team approach to nursing care and changes the plan of care as priorities change. The primary support nurse in the OR evaluates care by comparing the nursing care given with patient outcomes. The evaluation continues throughout the procedure and through postoperative assessments. Finally, the nurse gives an oral account of ongoing activities to the next shift or to the recovery room nurse. He/she also communicates with other nursing units and hospital departments when appropriate and documents all perioperative nursing care in the patient record.

Implementing the System

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n a decentralized nursing management system, the first step in introducing this concept was to involve the staff nurse of the special services. We reviewed nursing standards and hospital policies and then formulated the roles and responsibilities of the primary support nurse. Through this process, the commonalities of our nursing practice were reinforced. Because this move to include perioperative nurses in the primary nursing concept was motivated by our initial exclusion, we recognized the need to communicate our roles and responsibilities more thoroughly. We prepared written descriptions of perioperative nursing and presented our proposal to the hospital-wide primary nursing committee. A representative from the patient clinical services division was appointed to this committee. 497

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Evaluation

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e have found many benefits of incorporating the primary support nurse concept into primary nursing. Through the process of implementing the system, we identified and strengthened communication. The nursing staff, both from the clinical patient services division and the medical-surgical division, gained new insights and appreciation for the nursing process as it applies to short-term patient needs. All of the nurses became more aware of their areas of accountability and authority to direct patient care. Within the primary support nurse framework, interim care is planned and provided by the registered nurse who specializes in one particular aspect of the patient’s care and does so in a limited time setting. This care planning is usually accomplished independent of the primary nurse. Thus, a gray area of time and care is now clear. Notes 1. John Naisbitt, Megatrends (New Y a k Warner Books, 1982). 2. K L Ciske, “Misconceptions about staffing and patient assignment in primary nursing,” Nursing Administration Quarter@ 1 (Winter 1977) 61-68; G M Van Servellen, “Primary nursing, variations in practice,” Journal of Nursing Administration 9 (September 1981) 40-45. 3. Marie Manthey, “A theoretical framework for primary nursing,” Journal of Nursing Administration 6 (June 1980) 11-15. Suggested reading Kent, L A, Larson E. “Evaluating the effectiveness of primary nursing practice.” Journal of Nursing Adminstration 1 (January 1983) 34-4 1. Latz, PA, et al. “A framework for primary OR nursing,” AORN Journal 29 (April 1979) 959-972.

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Hepatitis B Vaccine Dose Could be Lowered The cost of the hepatitis B vaccine is one of the reasons it is underused, but a study at Walter Reed Army Institute of Research, Washington, DC, indicates that the dosage could be reduced and still be effective. Robert B. Redfield, MD, and colleagues administered the vaccine intradermally rather than intramuscularly in three doses to 25 seronegative health care workers. “We found no significant difference in seroconversion between the intradermal group (96%)and the intramuscular group (1 OO%),” said the researchers. The intradermal vaccine was one-tenth as strong as the usual strength for intramuscular administration. This reduced dosage represents a potential savings of 90% over the current vaccine, which costs more than $100 per person. The study is reported in the Dec 13 issue of the Journal of the American Medical Association.

Film Review: Laser

Technologyin the Operating Room The physics of lasers and the three types available for use in the OR are discussed in this 1985 videotape, Laser Technology in the Operating Room. It has a description of the safety precautions for staff and patients, suggested hospital policies and procedures, and protocol essential to establishing a laser surgery program. Judith Pfister of Education Design, Inc, presents the film using a distinctive narrative format. The 48-inch videotape is available in VHS, SP, Betamax I1 or %-inch Umatic ($50 extra). It can be purchased for $125 or rented for $85 for two weeks (a package of five videotapes costs $395). For orders, contact Communicorp, Inc, 805 S Main St, Lombard, IL 60148. CHARLOTTE HYER,RN AUDIOVISUAL COMMITTEE