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| Alex Bilbe is a Clinical Nurse Specialist in the Psychiatric Unit and Julie Purcell is Assistant Director of Nursing, Research and Projects, at St. Vincent's Hospital, Sydney. |
The 36 bed psychiatric unit within a Sydney Metropolitan Teaching Hospital has recently implemented the Primary Nursing (PN) model. This study examines the influence of PN on job satisfaction for the primary nurses employed. A questionnaire, consisting of a 5 point "Likert Scale" (Section A) and open ended questions (Section B), was utilised to assess nurses' perceptions of job satisfaction relating to primary nursing. Findings of Section A were analysed into positive and negative responses in the following categories: Support for nursing staff/interaction; Administrative/Management, Esteem; Autonomy; Status of Nursing; General Working Conditions; and Response to Primary Nursing. Findings of Section B were grouped into Client management; Collegial and Working conditions categories. Results indicate that nurses are satisfied with Primary Nursing for the following reasons: continuity of care and rapport; more responsibility; greater accountability for clients, and improved communication. It would seem, however, that there has been an increase in workload following the inception of Primary Nursing.
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The 36 bed psychiatric unit within a Sydney Metropolitan Teaching Hospital has recently implemented the Primary Nursing (PN) model. It most commonly serves as an acute admission centre for clients suffering psychotic episodes of mental illness.
As the inpatient unit is considered to be a "mental illness" service rather than a "mental health" service, it is not directly concerned with preventative methods involved with mental illness. Therefore, it may be perceived as reacting to the environment. For example, clients are usually brought into the centre by the Police, community health teams and/or family. For this reason it is an imperative policy for the inpatients' unit to have beds available for emergency situations. Unfortunately this policy occasionally results in compromises such as discharging clients before they are able to function purposefully in the community. However, individual needs after discharge are often dealt with by community-based managers.
The structure of the unit, in its medical paradigm, stabilises clients who present with exacerbated states of mental illness. However, once the acute phase subsides, these clients are often discharged to the community. Many suffer a chronic mental illness. Facilities which may enhance a higher level of functioning and improve quality of life are not available at the centre. For example: activity programmes, psychosocial sessions with psychologists, behavioural modification programmes and specialist training programmes for clients are not currently utilised. PN was implemented to replace the previous patient allocation model. The patient allocation model functions by the total nursing management of the client being shared amongst a number of nurses. (One nurse does not accept the responsibility for the overall care of the client during their hospitalisation.) Under the patient allocation model, the number of clients for whom a Registered Nurse was responsible varied from three to 12. This variability was due to there being four "teams", each under the management of one or two psychiatrists whose client load varied. One Registered Nurse would be assigned to each team for the morning and afternoon shifts, with a supervising "charge nurse" who was allocated no clients. Three nurses only were rostered for night duty at the centre. Two of the night nurses would take the responsibility of two teams each, and the other nurse would retain the "charge" position.
The central theme of PN involves the nursing care of a specific client being managed and coordinated under the continual guidance of one nurse. This contract commences from the time of admission through to discharge.
Optimally, the Primary Nurse liaises with other health care professionals to ensure that the client is provided with continuity of care.
When the Primary Nurse is absent from work, an "Associate Nurse" is allocated their clients. Coordination of client care is maintained through verbal and written communication to provide the client with a "24 hour a day service" (Reed, 1988: 385). In order to achieve a functional PN system, Armitage, Chapney-Smith and Andrews (1991: 414) claim the following points are essential:
In summary, therefore, PN is the delivery of comprehensive and individualised client care through the primary nurse who has autonomy, accountability and authority to act as the controller of nursing care for their client/s (Brooker, 1979: 2).
One of the reasons given for implementing PN at the centre was to enhance the nurse's role, thereby enabling them to become more involved in a multidisciplinary team approach to client care and management. Within the literature, there are numerous conflicting findings regarding nurses' perceptions of PN and its relationship with job satisfaction. According to Cardner (1981), Johnson, Morton, Walker & Whitehead (1990), MacPhail (1988), Mangelsdorf & Smith (1990), Reed (1988), Selick, Russell & Beckman (1983), and Stelling (cited in Stinson, Kerr, Giovannetti, Field & MacPhail, 1986), it seems that there are four main explanations for these inconsistent reports:
Motivation theory, as per Maslow (1954), suggests that individuals strive to fulfil needs in hierarchal order from survival to "self-actualisation". The higher level needs include achievement, recognition, autonomy, responsibility, accountability and decision-making. It may therefore be seen that nurses operating in a system which is designed to meet higher level needs, will reap the benefits related to job satisfaction. Many nursing researchers claim PN is specifically designed to meet these needs (Blenkarn, D'amico & Virtue, 1988; Macguire and Botting, 1990; Selick and Russell, 1983, and Reed, 1988).
Some studies have, however, found that the implementation of PN may lead to job dissatisfaction (Armitage et al., 1991; Mangelsdorf and Smith, 1990, and Perala and Hentinen, 1989). If job satisfaction levels are low prior to implementation of PN, the changeover may have adverse effects. Also, PN was seen to increase staff workload and paperwork leading to stress-related problems.
However, the general consensus of the literature is one of cautious optimism in relation to PN and job satisfaction (Blenkarn, D'amico & Virtue, 1988; Brooker, 1978; Carlsen and Malley, 1981; Ersser and Kleenan, 1990; Cardner, 1991; Macguire and Botting, 1990; MacPhail, 1988; Reed, 1988, and Selick, Russell & Beckman, 1983).
PN at the centre has been adapted to suit this busy unit with its high client turnover. In order to maintain staff morale, associate nursing has been compromised. In the absence of the primary nurse, a patient allocation system functions instead of associate nursing. Associate nursing was initially implemented, however, this system failed due to roster constraints. The roster is flexible and geared towards satisfying staff, rather than client needs, although by satisfying staff, client needs may be met indirectly. The Assistant Director of Nursing of the centre states that with the present stressful working environment, structural constraints, and lack of available facilities, the continuation of a flexible roster is a vital part of stabilising the work environment. If this flexibility were abolished, he believes there would be an increase in sick leave, a decrease in nursing staff retention and a decreased staff morale.
Within the PN model, the number of clients for whom a Registered Nurse is responsible varies from four to nine. This variability is due to the variation in the number of inpatients on any given day. Clients are now allocated to one of two "firms", each under the management of several psychiatrists. Primary nurses are allocated a client on their admission, dependent on several factors: the number of clients already allocated to that nurse, whether the client has previously been a primary client of that nurse, and the number of primary nurses on duty at the time.
Should a primary nurse be the only one on the shift, a part time RN may admit and assume the temporary responsibility for that client until the next shift, when the client would be allocated to an appropriate primary nurse. One Registered Nurse (usually a primary nurse or CNS) is assigned as the coordinator for the morning and afternoon shifts. This nurse is responsible, during that shift, for their primary clients only. Three nurses are rostered for night duty at the centre. Two of the night nurses take the responsibility of a firm each, and the other nurse retains the coordinator position (with their primary clients).
Plans for an acute unit have been approved. Funds for an occupational therapist (OT) and refurbishing to construct an activities art and craft area have also been approved.
Along with environment changes, nurses may find work more satisfying, therefore staff morale may be boosted by intrinsic rewards. The importance to nursing staff of a flexible roster may not be as apparent if job satisfaction is enhanced. The ultimate aim is to move towards an optimal level of client care. As the function of associate nursing is an integral part of this process, it is desirable that an acceptable system be designed.
Whilst there is a great deal of support for PN in nursing articles, it is difficult to ascertain the extent of PN in Australia, due to the lack of locally published data.
In view of the lack of substantial evidence to support PN over other nursing modalities, this study was undertaken to assess the effects of job satisfaction in relation to PN at the centre.
This project identifies problem areas, therefore new strategies may follow. Any changes will be re-evaluated after a six month period. The overall purpose of this study is to increase job satisfaction for nurses working at the centre.
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This project studied all 15 Registered Nurses employed as Primary Nurses at the centre. (A total of thirty-five nurses are employed).
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A questionnaire consisting of two sections (A and B) was utilised. The questionnaire was adapted from research tools used by Stamps and Piedmont (1986) cited in Johnson et al (1990: 45), and Brooker (1979). Section A consisted of a five point Likert-type attitude scale with randomly organised negatively and positively worded statements. Section B was a series of open-ended questions designed to encourage participants to discuss problems and benefits related to PN, and ways in which the system may be improved.
A Pilot Study was undertaken, during June, 1992, using eight nurses of various levels as subjects (all non-primary nurses). The research instrument was adapted as indicated by the findings of this study.
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A total of 15 subjects participated in the study. Of these, eight were N.S.W. State Registered Nurses, and seven Clinical Nurse Specialists. Time spent nursing in the mental health field ranged from six weeks to 27 years. Mean time spent in this clinical field (calculated on 14 values only) was 11 years and one month. Four respondents had previously worked as primary nurses in other units.
Questions have been categorised into groups including:
Administrative/management matters encompass the questions 2, 4, 14, 15 and 29. Respondents were divided in their opinions as to whether the clerical component of their work was excessive.
The large majority stated that more time was needed for the care of each client.
However, ten of the 15 total respondents agreed that there was adequate time for discussion with their colleagues about client care and problems.
It was surprising to find that all decisive respondents felt they had adequate control over their own work, whilst eight stated that they did not have sufficient input to the programme of care for their primary clients. (The majority of respondents disclosed that they had enough authority.)
Status of Nursing encompasses the questions 3, 8 and 9.
A small majority agreed that nursing is a long way from being recognised as a profession. Nine respondents felt that there were enough opportunities for advancement for the centre's Nursing Staff, versus five who did not.
Esteem encompasses the questions 7, 17, 19, 22, and 26.
The centre's primary nurses overwhelmingly felt that what they do in their work is really important, although one stated that they disagreed with this statement. Three respondents indicated that what they do in their job does not add up to anything significant as opposed to ten who responded positively to this statement.
Nine expressed pride in discussing what they do in their job, versus three who indicated that they did not.
General working conditions encompasses the questions 6, 12, 18 and 24.
Most staff, whilst agreeing that the pay is reasonable, considering the work performed (eight agreed, six disagreed), felt that an upgrading of nursing pay scales is required (nine agreed, six undecided).
It is a disturbing fact that most nurses studied were not satisfied with their job functions and, further, that their professional job ethics were sometimes compromised.
Response to Primary Nursing encompasses the questions 16, 25, 28, 29 and 30.
It is encouraging to find that seven respondents agreed that the level of client care has improved since the inception of Primary Nursing at the centre (five disagreed).
Nine respondents considered that there has been an increased workload following Primary Nursing. Five disagreed with this statement. (One respondent who disagreed, commented, however, that there had been an increase in client load of two to three clients per shift as a result of the introduction of Trainee Enrolled Nurses to the centre's Nursing establishment). Two respondents considered that continuity and compatibility of care by nurses who are not Primary Nurses was not a problem, five considered it a minor problem, and eight considered it to be a problem.
One respondent considered assignment to a difficult client to be a major problem and four nurses considered it a problem. (One of the respondents who thought it was a problem added "if the nurse is a primary nurse".)
Seven thought this state to pose a minor problem, and three not a problem at all.
Client relationships with staff were considered to be a problem for three of the respondents, a minor problem for five, and for two not a problem at all.
(Number of respondents indicated in brackets).
To the question "What changes, if any, would you suggest should be made to primary nursing as it is practised at the centre?", the following responses were obtained:
(5) Associate nurses would assist in improved continuity of care and
sharing of the workload, particularly admissions;
(2) Allocation of a stable workload to primary nurses would lead to an
improved consistency of care;
(2) Consideration of client dependency when allocating clients to staff.
Other comments included; that primary nursing should be undertaken "on a small scale i.e. to limit to a smaller number of patients", "scrap it", "fine tuning needed", requirement for "improved relationship and communication with the follow-up agent...", "more team work (needed) with Doctor", "review of the coordinator's role as primary nurse", "primary nurses may need to learn interview skills /councelling (sic)".
To the question "In what ways are you satisfied with the present situation in relation to primary nursing?", responses were: (5) Improved continuity of care;
(5) Improved rapport;
(4) More responsibility;
(2) Greater accountability for clients;
(2) Improved communication.
Other respondents mentioned their satisfaction with autonomy, increased case manager contact, "wholistic care", increased job satisfaction and integrated notes/documentation. One very positive comment was "far better than team nursing".
To the question "Please make any other comments regarding primary nursing at the present time", many responses were similar to the above two questions. One comment unique to this request stated "some staff don't seem fully committed, call it pretend or pseudo primary nurses (sic)". Another, "it is still in its infancy... and will need to be adjusted every so often" (to cope with change).
To the question "In regard to your work please list the sources of satisfaction you gain from your job", the following were included:
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It would appear, from the findings of this study, that nurses are satisfied with Primary Nursing for the following reasons: continuity of care and rapport; more responsibility; greater accountability for clients, and improved communication. It would seem, however, that there has been an increase in workload following the inception of Primary Nursing. This may have been influenced by the employment of two student enrolled nurses coinciding with the implementation of Primary Nursing.
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An investigation of job satisfaction in nurses, prior to the implementation of Primary Nursing would have been useful, in order to undertake a comparative analysis.
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It appears that increased input into the programme of care by Primary Nurses may further improve job satisfaction for many. An investigation into the job functions of Primary Nurses is an area for further study.
The re-introduction of Associate Nurses would appear to be desirable for the improvement in continuity of care, communication and sharing of workload. This project has identified several areas requiring attention. Any changes made to the Primary Nursing programme will be re-evaluated after a six month period.
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