Nina Fraser, BSc, DPSN, RN, is clinical services manager, Marie Curie Centre, Edenhall, Hampstead, London; Jane Eades, BA, RN, is clinical nurse specialist; Imelda Glackin, BSc, RN, is senior sister; Jacqueline Holmes, RN, is senior sister, Marie Curie Centre, Edenhall, Hampstead, London.
A fundamental principle governing the delivery of effective palliative care is that of a patient-centred approach. So it would surprise many to learn that nurses working in a specialist palliative care unit which prides itself on the positive feedback it gets on patient care felt they needed to develop a more patient-centred approach.
However, as a newly appointed group of senior nurses working in such an environment, we felt well placed to take a fresh perspective on the unit’s working patterns. Our desire to switch from a traditional style of nursing to a truly patient-centred one stemmed from more than just a wish to influence the culture in the unit. We shared the belief that many nurses in the unit were unable to realise their potential because of the existing work methods and the fact that their status not always perceived as being equal to that of other members of the multidisciplinary team. In addition, we were experiencing a problem with recruitment and retention.
The work of Binnie (2000) led us to believe that we needed to foster an environment within which nurses’ individual needs would be accorded as much importance as the care they were expected to give to patients. By addressing each person’s development needs we hoped to foster their enthusiasm and commitment, and give them confidence to respond to the challenges of their clinical practice.
Our individual experiences and a review of the literature led us to believe that the most appropriate way to achieve our goals would be to introduce primary nursing. Although the wards were practising team nursing this system failed to facilitate the goals we wanted to achieve. Box 1 compares the two approaches. This article describes the beginning of our journey, examining the preparation we undertook before we switched to primary nursing.
Sharing a vision
Wright (1990) believes that a top-down approach, in which change is imposed from above, results in resistance among the staff who will be expected to implement it. We shared his belief that long-lasting, effective change would be achieved only if all staff shared a vision of the future, had ownership of the vision and were willing to work towards it. However, before we were in a position to facilitate this bottom-up approach at ward level, we spent time preparing together.
As a group of four senior nurses (clinical services manager, clinical nurse specialist and two senior ward sisters) we had diverse roles, skills and levels of experience. It was clear from the outset that if we were to succeed in meeting our aims, we would need to ensure that we shared the same vision and commitment.
The exercise of formulating a vision facilitates reflection on ‘where we are now’ and ‘where we want to be’. We used it to provide direction and also to provide us with measurable outcomes to monitor the progress being made. The process of setting our goals helped us to identify where our opinions and priorities differed. It also highlighted areas where we had a knowledge deficit.
Current knowledge base
Further preparatory work involved a literature search, which showed us that primary nursing gained prominence in the 1970s through the work of Marie Manthey at the University of Minnesota Hospitals, USA. Since then there has been a steady increase in the amount of literature published. Primary nursing was introduced in the UK in the late 1980s. However, our review found little relating directly to our specialist area. Despite this, the literature reinforced our belief that we should adopt the concept.
What is primary nursing?
Primary nursing can be viewed both as a philosophy of care and an organisational design (Hegyvary, 1982). It is a forum for increasing the respect and autonomy of the nurse, who in a primary nursing role is responsible for a caseload and is supported by a small team of associate nurses (Binnie, 1989). The essential elements of primary nursing are recognised in the nursing literature as accountability, authority, autonomy, advocacy, assertiveness, continuity, collaboration, communication, commitment and coordination.
These features complemented our vision for the unit, confirming our belief in the appropriateness of primary nursing. The literature also highlighted the pitfalls we might encounter. Implementing primary nursing would involve nurses undertaking a critical analysis of their traditional nursing practice, which could be challenging. By putting forward the idea of change, it could appear that we were implicitly suggesting there was something wrong, which could in turn provoke resistance (Wright, 1990).
Clarifying the vision
If the change to primary nursing were to be successful, each member of the nursing team and the wider multidisciplinary team would need to value nursing, and consider it worthwhile, important and therapeutic (Wright, 1990). We recognised that careful planning and a sensitive approach would be needed to make the change.
After we had read the available literature, we took time to ensure that we had a shared understanding of the concepts and terms. Through presentations and discussions we explored the core concepts of therapeutic nursing and primary nursing. As Walker and Avant (1988) suggest, being precise about our definition of the concepts would make it easier to promote understanding among our colleagues, which would be vital for success. This exercise also gave us confidence: we knew we were speaking the same language, our aims became clearer and our commitment stronger.
After we had formulated our vision and explored the concepts of therapeutic and primary nursing, we used the SWOT analysis (strengths, weaknesses, opportunities and threats) as a framework for identifying our internal strengths and weaknesses, as well as our external opportunities and threats.
SWOT analysis is recognised in business environments as a useful tool in the preliminary stages of decision-making and as a precursor to strategic planning (Bartol and Martin, 1991). But, as Balamuralikrishna and Dugger (1995) point out, the idea of using it in other settings is not new. Within the nursing profession, Bowles (1997) offers it as an ideal first step to facilitate the formulation of a shared vision since it can be conducted with a large number of staff.
Our desire to facilitate a systematic and rigorous change process led us to use a SWOT analysis to underpin the formulation of our shared goals. We were keen to analyse the situation as it was, to provide a context for our vision and our impending development in nursing practice.
A SWOT analysis involves listing specific items related to a situation, under the headings of strengths, weaknesses, opportunities and threats. This took place as a facilitated discussion and provided us with a detailed analysis.
However, we found that sometimes we needed to be better at distinguishing strengths from opportunities. Similarly, we found we needed to be more focused to ensure we appropriately identified weaknesses and threats. This was aided by the definitions of the aims in each category, as well as by the responses to the open questions which were intended to prompt discussion (Box 2).
Our SWOT analysis provided us with a picture that revealed many surprising strengths. For example, two well-respected members of staff had previous experience in primary nursing. We also felt that because a new nursing structure had been implemented, bringing with it a feeling of optimism in the two wards, the timing was right to develop our plans. Our analysis, however, also exposed weaknesses that would need careful consideration.
Many of our nursing colleagues were unsure of how primary nursing would alter or enhance what we were already doing. The feeling that unequal power relations existed in the wider team also had the potential to work to our disadvantage if this was not acknowledged in our plans.
Although we were aware that there might be varying perceptions of our strengths, weaknesses, opportunities and threats among the different groups consulted, we felt that the analysis of our situation gave us a baseline from which to continue with our developments in practice. Taking the various attributes into consideration also enabled us to plan our strategy for change.
We were aware that our SWOT analysis had taken place at the beginning of our journey and that our situation would change. Balamuralikrishna and Dugger (1995) recommend that analysis should be repeated frequently and we plan to undertake a further analysis at a later stage.
Few would disagree that nursing in a palliative care setting demands a patient-centred approach. However, our biggest challenge was to establish exactly what was stopping nurses from implementing this. As a group of senior nurses, we took the opportunity to clarify the concepts of therapeutic nursing and primary nursing, to facilitate consensus on a shared meaning.
Further examination of the terms ‘therapeutic nursing’ and ‘primary nursing’ enabled us to develop a shared vision for the contribution nursing can make in the specialty of palliative care. We undertook specific activities to help clarify our goals. First, discussions were facilitated in our small group regarding where we were as a team and where we wanted to be in future. This was enhanced by undertaking a SWOT analysis to assist planning. Finally, a literature search for articles on primary nursing enabled us to immerse ourselves in the concepts as they applied to other clinical environments.
Key to our success in this initial phase was our ability to develop our shared vision as a senior nursing team. As our goals became clearer, we identified that the existing system of team nursing restrained staff from developing the 10 elements of primary nursing that we felt were essential to professional practice. Thus, the vision that we are moving towards encapsulates the essence of patient-centred nursing within a structure of primary nursing.