REASONS have been offered to explain the wi‘d espread difficulty in recruiting and retaining highly competent nurses in hospital practice (Aiken & Mullinix, 1987). When nurses are able to meet their basic needs for salary and convenience of work schedule, they will choose practice settings that reflect the professional values that are meaningful to them (Roberts, 1989). Many persons, including nurses, come to understand the essence of nursing care from a personal hospital experience. From my own experience of hospitalization, I know that I want a nurse who understands what my illness means to me, who knows what makes me feel better or worse, and who will be committed and accountable for helping me to achieve the best possible outcome. I want a nurse who can help me find realistic hope when I feel hopeless, helpless, and disconnected from my life. This kind of knowing between a nurse and patient can only happen in the context of relationship, and is best operationalized in a primary nursing practice model where the practice system is developed from a network of values of care, rather than simply a nurse-patient assignment method (Clifford, 1990). There has recently been criticism of primary nursing centered around issues of cost effectiveness, efficiency, and convenience for nurses, physicians, and other hospital members (Bennett & Hylton). I would like to share an experience from my own primary nursing practice that has impressed on me the central nature of relationship to any professional practice, and the fact that continuity of care is the right of both the patient and the nurse. Jack, a 35-year-old businessman, had an abscessed tooth that he ignored, resulting in a cellulitis in the soft tissue of his throat. He came to the emergency room with his throat swollen to the point that his airway was compromised. Following an incision and drainage of his throat, Jack developed a fever and began to show signs of sepsis. His infection had migrated to the mediastinum and spread throughout the thoracic cavity. This was a catastrophe for Jack. Taking care of Jack from day to day as my primary patient, I began to experience the truth that nursing care was a critical and essential element of his recovery. I began to see that I had an important contribution to make and
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that I could make a difference and influence the outcome of Jack’s illness. It was my responsibility to develop a plan of care uniquely suited to Jack’s needs and to maintain a relationship with Jack’s family that communicated to them a realistic hope about what could be achieved. I don’t feel that I was more or less perceptive than others involved in Jack’s care, but by virtue of the fact that I took care of him almost every day, I was able to develop an intuitive sense of the subtle changes in Jack’s condition. I feel that this continuity and our mutual, tenacious commitment to healing allowed Jack to respond to the treatment of his illness and disease. I strongly believe that Jack could not have survived outside of a primary nursing system. If continuity of care was not valued, subtle responses and changes to treatment may not have been appreciated. If there was no commitment to the nurse-patient relationship or empowerment to ensure the plan of care was carried out, the knowledge on which successful interventions were based would not have been available. Primary nursing is an experience, not a structure. It is experienced in the context of the lived nurse-patient relationship, which is the structure of primary nursing. The fundamental values of primary nursing are the same for all patient care settings, and the experience of primary nursing is similar for all primary nurses. The values of a continuous, caring presence, collaboration with peers and physicians, and accountability and commitment to the best possible outcome empower nurses to achieve excellence in their practice. How these values are implemented may vary considerably from setting to setting. The structure that is chosen may be awkward, more chaotic, less neat and clean than other models, but a committed primary nurse, the type of nurse all excellent institutions wish to attract, will find ways to overcome obstacles that are present in any system. As for me, I would not practice in any system where these basic values would not be accepted or allowed to be expressed.
References Aiken, L. H., & Mullinix, C. F. (1987). The nurse shortage: Myth or reality. New England Journal of Medicine, 3 11, 642. Bennett, M. K., & Hylton, J. P. (1990). Modular nursing: Partners in professional practice. Nursing Manugenenr, 21, 20-24. Clifford, J. (1990). Professionalizing a nursing service: An integrated approach for the management of patient care. In J. C. Clifford & K. J. Horvath (Eds.), Advancing Profeesionuf Nursing Practice (pp. 30-50). New York: Springer. Roberts, M., et al. (1989). What to do about the nursing shortage. Hospital Topics, 67, 8-20.