Journal of Clinical Nursing 1992; 1: 95-99

An analysis of the changes involved in the introduction of the nursingprocess and primary nursing using a theoretical framework of lossand attachment

, : ,,i V ri; ;(, D O N N A M E A D MSc, RGN, RNT, RCNT, DANS, Dip N(Lond)-''• . : i ' ; : ^ i - :(>n • Director, Research and Development, Mid and West Wales College of Nursing and Midwifery,

University College of Swansea, Swansea, UK

R O S A M U N D BRYAR BNurs, MPhil, RGN, NDN, RHV, RM, Cert Ed(FE)Senior Lecturer in Nursing Studies, Teamcare Valley si School of Nursing Studies, University ofWales College of Medicine, Cardiff, UK

Accepted for publication 12 November 1991

Ol K ' i

'1 'h

••IV - . n f i • l ; . , i - i . ' ; i i n i ;

! ' ! / Uli/j"

Summary ,

• The nursing process is an innovation which has had a great effect on nursingpractice.

• Primary nursing is an innovation currently having profound effects on thedelivery of nursing care.

• In this article a theoretical framework of loss and attachment (Marris, 1985) isused to analyse these innovations.

• Data from studies of the nursing process (Bryar, 1985) and primary nursing(Mead, 1991a) are used to argue that changes in working practices may result in aperiod of loss and mourning. Nurses must have time to work through this periodof mourning if change is to be successfully implemented.

A'f)/n'or(/i.-primary nursing, nursing process, concept of loss. ; ^ .J AI."-'

Introduct ion >•>•»' '•••'>

Nursing has experienced two major developments in re-cent years, the nursing process and primary nursing, whichare similar in many respects, not least because they share acommon intent: to individualize patient care. In thenursing process the mechanism for this is to adopt aproblem solving, systematic approach to planning andproviding care for an individual patient, whereas in prim-ary nursing the mechanism involves the delivery of a

Correspondence: Rosamund Bryar, Teamcare Valleys, WhitchurchHospital, Whitchurch, Cardiff CF-f 7XB, UK,

comprehensive nursing service, through the medium of thenurse/patient relationship, by an autonomous practitioner,from admission to discharge.

The need for both these innovations was identifiedinitially by practitioners in the USA in response toperceived shortfalls in the way care was delivered (McFar-lane, 1975; Manthey, 1980; Pearson, 1983).

de la Cuesta (1979) has described the process by whichthe nursing process was promoted in Britain by nurseacademics and nurse leaders rather than developing fromnursing practice experience. In 1974 Baroness Macfarlanegave the first lecture on the nursing process in Britain. By1977 it was included in the General Nursing Council's

95

96 D. Mead and R. Bryar

syllabus for training and by 1980 it was included as Rule 18in The Nurses, Midwives and Health Visitors Act 1979.This put the seal on what was to become a top downapproach to the introduction of the nursing process whichmet with much resistance from the profession. It isapparent that this strategy for change was misguided: withsubsequent effects from which the profession has neverreally recovered.

The approach to the introduction of primary nursingmight appear to be different to the approach adopted withthe nursing process. There can be little doubt that primarynursing has captured the imagination of British nurses.For example, almost weekly there are articles in thenursing press about primary nursing and nurses fromthroughout the country are registered with the King'sFund Primary Nursing Network (Primary Nursing News,1991). What has been particularly encouraging, though, isthat this surge of enthusiasm has come from practisingnurses as a set of local initiatives. This is a far cry from theway the nursing process was imposed on ward staff bynational, regional or district edict.

What follows is an analysis of the feelings of nurses andmidwives who have experienced the introduction of thenursing process and primary nursing. These feelings arecompared and analysed within the theoretical frameworkof loss, bereavement and grieving developed by Marris(1985).

Reactions to the nursing process

Bryar (1985) was involved, between 1979 and 1982, in theintroduction of the nursing process into a maternity unit aspart of an action research project which aimed to indi-vidualize care and provide continuity of care. Many of themidwives in the hospital and community were very en-thusiastic and actively participated, however some mid-wives did not react so favourably. One sister refused toparticipate because she felt that the ward was alreadyproviding individualized care. A labour ward manageroffered support for the project in the steering group butdid not want the labour ward to participate as this area was'special'. A senior sister expressed her concern about thecare the women on the ward had been having before thechange to 'patient' allocation and care planning.

In the antenatal area midwives reacted with fear andanxiety to the idea that they would care for a womanthroughout her pregnancy and be responsible for her, asopposed to their pre-existing doctor-support role.

In the maternity unit where the nursing process wasintroduced there was attention to paperwork rather than tothe actual care given and throughout the project a total lack

of questioning of the care that was being given wasapparent.

The reactions and feelings experienced by the midwivesare similar to those encountered in a bereavement. Marris(1985) argued that the concept of grieving could be appliedto many situations which were not ordinarily thought of asbereavement. Moving house for instance, or starting a newjob may involve the sacrifice of familiar relationships withneighbours, colleagues or a community whose interests oneshared and, although the new house, or new job may wellbe better, that does not overcome the need to mourn.

It can be seen, therefore, that many of the reactionsassociated with grief were experienced by the midwivesand that these feelings are similar to those outlined inmodels of grief (Kubler Ross, 1969; Murray-Parkes, 1980).These included: the sister's anger at the thought that thecare being provided was now deemed to be not goodenough; the labour ward managers' denial that the changewas necessary in her area; the sister who yearned for thepast, continually commenting on the old days and care shehad given; the antenatal ward staff who experienced fearabout their new roles and responsibilities. Lewis (1961)commented: 'no-one ever told me that grief was so muchlike fear'.

Lancaster & Lancaster (1981) noted that changes inworking practices may involve for staff a fear of theunknown, fear of failure, fear that not enough will beknown about the new situation and fear that they will notbe as useful a member of the ward team as they are now.

In concentrating on the paperwork and not with thechanges required in care delivery a form of denial is takingplace. Individuals are going through the motions of accept-ing the situation by concentrating on the care plans, butcannot begin to work through their grief because they havenot yet confronted the reality of the situation, which is thatthe way in which care is delivered needs to change and thatin order to achieve this a role change for the midwives ornurses concerned is required.

For many nurses and midwives the changes necessary toimplement the nursing process threatened their verybeing; their previous integrity as experienced, competentpeople well used to their work situation was threatened.This personal threat created by change, whilst understand-able, is one of the prime causes of resistance to change(Research Unit in Health and Behaviour Change, 1989).

React ions to p r imary nursing

At the moment when a ward or unit embark on the changeto primary nursing it is generally because the individualsconcerned perceive the need for it and have discussed this

Primary nursing using a theoretical framework of loss and attachment 97

amongst themselves and agreed upon its implementation(Mead, 1991a, b). Because the change is wholly anticipatedand welcome it could be expected that the feelings exper-ienced by those who were obliged to implement thenursing process will not occur. However, this does notappear to be the case and many ward sisters experience arange of emotions which are unexpected and unwelcome.Some of these are described below and were obtained aspart of the Mead (1991a) study.

<•''.!.

FEAR AND PERSONAL THREAT

'What if I make a mess of this and make a fool of myself?';'what if in giving the primary nurse the environment toassume the responsibility for patient care, one of themmakes a mistake.''; 'what happens to my role now. I will nolonger be needed'; 'I'm not sure if I know enough aboutprimary nursing to lead this change.'

PINING • " V ' "

'It's very difficult when the consultant comes to the ward.We can't do a ward round like we used to and this alwayscauses tension for me and the staff.'

BARGAINING

'We have tried to do primary nursing and it hasn't worked.If I had more staff, less part-time staff and control over thenight staff, I could do it.' i'lrm/ ; .:! nnf .-: -, ;../. -;

DENIAL ri;.: ,.rii!i

•>'.)•:>•'..

•"...; . - , - i V .\U'- <': b n

'We have tried to do it (primary nursing) on this ward butour speciality is unique. It isn't appropriate for us'. (Thismay be the case—but this claim was made from indi-viduals working in many specialities including coronarycare, ITU, short-stay units, GP wards in communityhospitals, gynaecology, midwifery and mental handicap.)'We have primary nursing on this ward. We have a notice-board to indicate which nurse is looking after whichpatient.' Where this activity occurs in the absence of anychange in the practice of nursing then this also is a failureto accept the reality of primary nursing—by concentratingon the notice-board and not in a change in the way inwhich care is delivered.

It can be seen that many of these feelings are similar tothose experienced during imposed change such as theintroduction of the nursing process and also resemble

those experienced during a bereavement when an indi-vidual mourns a loss.

Feelings of loss occur in relation to anything for whichthe person has an attachment—anything which is prized orcherished. What is being lost during the change to primarynursing which is over and above that being lost for thenursing process.' The changes involved in primary nursingmay challenge the individual nurse more fundamentallythan the changes involved in adopting the nursing process,for example, there may be a greater feeling of loss ofpredictability and loss of self.

LOSS OF PREDICTABILITY

When primary nursing is introduced there are major rolechanges for all concerned. The loss therefore involves aloss of predictability. The past was predictable—ward staffcould be fairly certain about the form the day would take;with such predictability comes security.

Even though the change to primary nursing is welcome,in the transition there is a loss of meaning and the staffneed an opportunity to make sense of this experience.

LOSS OF SELF

The fundamental crises of bereavement come not from theloss of others but from the loss of self (Marris, 1985). As inall personal relationships, we define ourselves, in part, bythe person/people/objects or activities that are importantto us and to which we relate daily. When we lose such aperson, object or activity, we lose a part of ourselvesbecause we lose in part, the way we define ourselves. Bylosing predictable nursing activity in the change to primarynursing we lose a part of ourselves.

These points are raised because so many ward sisters areencountered who embark on the change to primary nurs-ing with such enthusiasm and high expectation. Primarynursing entails fundamental changes in the roles of, andrelationships between, all nurses, other staff, and thesisters on a ward. Due to the feelings arising from the lossof previous methods of work organization, disillusionmentand frustration occur to the extent that some ward sistersgive up with a subsequent sense of failure being experi-enced.

There are many excellent examples which show thatthese problems can be overcome by using a well plannedchange strategy (see for example, Ersser & Tutton, 1991).Fitzgerald (1991) cautioned, however, that the changestrategy is sometimes concentrated upon at the expense ofthe change. When individuals experience a well planned

98 D. Mead and R. Bryar

change strategy in which time is allowed for changes to beinternalized, sufficient knowledge to be gained and a forumprovided for discussion which results in ownership ofthe changes, then primary nursing can be successfullyimplemented (Binnie, 1987; Stewart 1991).

The named nurse

We may be about to face history repeating itself: primarynursing being imposed on staff from above and resisted bythose whose job it will be to implement it. That both theWelsh Office (1991) and the Department ofHealth (1989)have pledged support for primary nursing in their respect-ive strategy documents should be seen as signalling awillingness to facilitate the spread of primary nursingrather than an intention to force its introduction into allareas. However, the result in some areas is enforced changewhere health authorities/regions have included primarynursing in their mission statements and staff have subse-quently been urged to begin primary nursing by a particu-lar date. This approach failed with the nursing process andit will fail with primary nursing because neither are eventsbut processes dependent on acceptance and internalizationof ideas by individual nurses and midwives; and bothinvolve a variable application in practice which is refinedand modified over time. Furthermore if this initiative doesnot continue to be practice driven then we risk a 'one rightway approach' being advocated by those who would lead it.

Marris (1985) has also argued that the process of reformmust always expect and encourage conflict. Whereverpeople are confronted with change they need the oppor-tunity to react; to anticipate their own ambivalent feelingsand to work out their own sense of the change. Theintroduction of change must respect individuals differingexperiences so that groups of nurses can make changeswithout the intrusion of alien concepts—which is howother people's notion of primary nursing may be per-ceived. There must be time and patience because theconflicts for each individual involve not only the accom-modation of diverse interests, but the realization of anessential continuity of meaning. Each of the principlesoutlined by Marris (1985) corresponds with an aspect ofgrief resulting in, in Marris's term: 'a crisis of reinte-gration' which can neither be escaped nor resolved byanyone on behalf of another nor hurried.

When the would-be change agent is preoccupied withthe powers they respect and are impatient to implementthe change they often try to save themselves the time andenergy of further conflict by:• co-opting agreeable representatives of public opinion;• out manoeuvring attempts at organized opposition;

• fragmenting criticism and overwhelming it with expertknowledge (see for example Hegyvary, 1982).

It's not that the change agent's proposal is unfair neces-sarily, for example, there is sufficient evidence that there isa body of nursing opinion which supports primary nurs-ing—but nurses may find difficulty in reconciling them-selves to the loss of familiar practices in terms of someutilitarian calculation of the common good—even if that isimproved patient care/patient satisfaction. People have tofind their own meaning in changes before they can livewith them.

Marris (1985) further argued that everyone in an organ-ization understands their job—the purposes it satisfies, itsgive and take, the loyalties and rivalries which it implies asa familiar pattern of relationships on which they rely tointerpret the events of the working day. This definition oftheir occupational identity represents the accumulatedwisdom of how they handle their job, derived from theirown experience and the experience of all who have had thejob before or share it with them. Change threatens toinvalidate this experience, robbing the person of the skillsthey have learned and confusing their purposes.

Conclusion ;r« iH :JI

Most nurses have little say in the decisions which deter-mine the policy of the organization; but collectively theyhave great power to subvert, constrain or ignore changesthey do not accept. Alternatively, they have the power toexpedite change because, after all, they do the work. Ifinnovation is imposed without the chance to assimilate it totheir experience, to argue it out, adapt it to their owninterpretation of their working lives, then they will do theirbest to fend it off. This was learned through the introduc-tion of the nursing process and if we ignore this historythen we will be condemned to relive this experiencethrough the introduction of primary nursing.

Acknowledgment

The contribution of Liz Adair in the preparation of thispaper is acknowledged. t;-; o.

The experiences of the midwives referred to in thispaper are based on data collected by Bryar (1985) as part ofa research project which involved implementing the nurs-ing process into a midwifery unit and by Mead (1991) aspart of a project which involved asking ward sisters aboutthe clinical innovations they would wish to adopt inpractice. The latter project is funded by the Department ofHealth and commissioned by the Welsh Office. ,.«, > i:

Primary nursing using a theoretical framework of loss and attachment 99

References

Binnie A. (1987) Primary nursing, structural changes. Nursing Times8.3(39), 36^37.

Bryar R. (1985) A study of the introduction of the nursing process ina maternity unit. M.Phil Thesis, South Bank Polytechnic, Lon-don.

de la Cuesta C. (1979) Nursing process: from theory to implementa-tion. MSc Thesis, University of London.

Department of Health, Nursing Division (1989) A Strategy forNursing. HMSO, London.

Ersser S. & Tutton E. (1991) Primary Nursing in Perspective.Scutari Press, London.

Fitzgerald M. (1991) Making things happen. Nursing Times 87(30),25-27.

Hegyvary S.T. (1982) The Change to Primary Nursing. The C.V.Mosby Company, St Louis.

Kubler Ross E. (1969) On Death and Dying. Macmillan, New York.Lancaster J. & Lancaster W. (1981) Concepts of Advanced Nursing

Practice: The Nurse as a Change Agent. C.V. Mosby, St Louis.Lewis C.S. (1961) A Grief Observed. Faber & Faber, London.Manthey M. (1980) The Practice of Primary Nursing. Blackwell,

London.

Marris P. (1985) Loss and Change. Routledge & Kegan Paul.,London.

Mead D. (1991a) Innovations in Nursing Care. A study commis-sioned by the Welsh Office, Nursing Division.

Mead D. (1991b) An evaluation tool for primary nursing. NursingStandard. 6(1), 37-39.

McFarlane J.K. (1976) A charter for caring. (RCN Nursing Lecture)Journal of Advanced Nursing 1 (3), 187-196.

Murray-Parkes C. (1980) Bereavement. Studies of Grief in Adult Life.Penguin, London.

Pearson A. (1983) The Clinical Nursing Unit. Williams HeinemannMedical Books, London.

Primary Nursing News (Newsletter) (1991) King's Fund Centre forHealth Services Development, London.

Research Unit in Health and Behaviour Change (1989) Changing thePublic Health. John Wiley and Sons, Chichester.

Stewart N. (1991) A structured approach. Nursing Times 87(30),28-29.

The Nurses, Midwives and Health Visitors Act 1979 (1979) HMSO,London.

Welsh Office (1991) Strategy for Nursing in Wales into the 1990's.Welsh Office, Cardiff