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Primary Nursing and the 12-hour Shift

The logistical problems of implementing Primary Nursing on a unit with 12-hour shifts can seem insurmountable. However, like most other complex problems, careful analysis of reality clears the path for an effective solution. My analysis leads to the following conclusions:

  1. A 12-hour schedule can accommodate short term patients.
  2. Some degree of continuity of assignment is possible with 12-hour shifts.
    For example: Two 12-hour shifts in a row, with the third one two days later provides maximum continuity for a patient with a 4-5 day LOS.
  3. The problems presented by mixing 8- and 12-hour shifts, coupled with the Primary Nurse assignment are huge, but not unsolvable. The largest is probably who gets the patient mid shift?
  4. Changes in how we think about Primary Nursing can free us to see solutions. Specifically:
    • Short term patients need a Primary Nurse just as much as long term patients. The difference lies in the goal setting. Short term patients need short term goals, not significant “life style interventions.”
    • A Primary Nurse/patient relationship is not a marriage. When it doesn’t make sense to continue the relationship (for instance, because the nurse is not working for the next several days) a reassignment is in order.
  5. The most serious logistical problems exist because the staff has not discussed their questions and expectations and arrived at mutual answers by consensus. Specifically, the staff needs to answer, for themselves, the following questions:
    • How soon after admission should a patient be assigned to a primary nurse?
    • Who will have responsibility on this unit to verify that assignments/selections are occurring within that time frame?
    • Who is responsible for shift-based assignments? How will the primary nurse relationships be available to that person?
    • Under what circumstances can/will/should a primary nurse be reassigned (for example: when she will be off duty for the next several days, because of room location problems, when a patients care needs exceeds her level of competence, when comparative case loads are severely unbalanced)?
    • What will happen when a primary nurse comes on duty mid-shift of a nurse who caring for his/her patient? Is the patient reassigned or not?
    • Under what circumstances might it be appropriate to reassign daily care to another nurse even if the primary nurse is on duty?

My conclusion is that the increased acuity, increasingly rapid patient turnover, frequent changing of skill mix in the past 10 years, and the constant efforts to drive down staffing costs have resulted in an absence of clearly defined care delivery principles. In the vacuum created by that absence, the organizing principles for care delivery reverted again to our beloved FRED: Frantically Running Every Day. This is task based nursing. Period.

In order to practice Relationship-Based Care there needs to be clearly thought out, value-based care delivery principles. These principles must speak clearly to responsibility for care management and coordination within the context of an intentionally established relationship between a Registered Nurse and the patient or their family. All the other elements of leadership, teamwork, resource management, etc. are essential in order to maintain the healing environment patients need and deserve. The unit staff have the wisdom they need to answer these questions. If they have a good understanding of the principles and reasonably good interpersonal relationships, they will consistently come up with the right answer for their unit. In fact, they are the ONLY people who can.


1. amy - March 6, 2010

primary nursing does not and will not work in todays world. it has been proven in the evidence-based research over the past 10years. the fact that you are writing about this & saying it should be implemented is only enraging staff RNs. 8-hr shifts don’t work… I just had all the nurses sitting around me say they would quit & go somewhere else for a 12hr shift. we will all quit. way to go to save on employee satisfication, increased patient satisfaction, and retain & retention rates.

mariemanthey - March 16, 2010

I am really interested in learning more about the evidence-based research that proves Primary Nursing doesn’t work in today’s world. In reality it works with any shift configurations and skill mix. It is very flexible: common sense in implementing the four principles is what it takes.
No one says you have to work 8 hour shifts to do Primary Nursing. Don’t get the two things mixed up. There are lots of studies about the 12 hour shift that may be motivating hospitals to think about reverting back due to safety, costs, etc….but Primary Nursing doesn’t require 8 hr. shifts.
I would like to discuss this further, and am interested in that research.

2. diana alemar - November 18, 2010

Hello Ms. Manthey,
I am a CNL student at Huntern College School of Nursing City University of New York. As a CNL student I have a capstone project. The capstone project is helping my institiution implement the primary nursing role in an ambulatory care setting (my microsystem). The pilot will be a segment of my microsytem; primary care internal medicine diabetic patients. We have 3 RNs in this area, about 800 diabetics. Any ideas, advise or articles books that you can point me to would be of great help.

mariemanthey - November 25, 2010

This will be an interesting capstone and I hope you will let me know how it goes for you. My basic advice is for you to pay close attention to the four organizing principles of Primary Nursing and to thoroughly understand them. Next, invite the nurses whose practice will change to explore the role configuration they currently have in the context of the role they would like nurses to practice if it were their loved one receiving the diabetic care, and to do this in the context of what they know about the clinical care setting. With those two pieces in place, the involved staff should follow the basic outline of implementation as described in Chapter four of THE PRACTICE OF PRIMARY NURSING and decide how to change current practice in order to implement the principles.

A nurse researcher named John Nelson has a complete bibliography of Primary Nursing literature and I suggest you contact him directly for information about pubications, research, etc. relevant to your work. His name is John Nelson and his email is jn@hcenvironment.com

3. Diana Alemar - November 26, 2010

Thank you! I will keep you posted on the progress.

4. Rebekah Lindsey - February 8, 2012

Hi Marie! I am a nurse in a large neonatal unit. A co-worker and I are helping implement relationship-based care. I plan on reading your book. We need all the help we can get with the nitty gritty details, if you know what I mean. Our nurses work 12 hour shifts. The scheduling/assigning part of it is the hardest.
Rebekah Lindsey

mariemanthey - April 22, 2012

Good for you. Keep checking the website of Creative Healthcare Management for tools you can use to help. Let me know how I can help. Is your Nurse Manager supportive?

5. Marie Michlik - February 9, 2012

I work on a Heme Onc floor, in a large cancer hospital in NYC, where the length of stay can be 3 days for chemo to 2 months for count recovery and complications. I have been there over 20 years, straight from college and could never imagine working anywhere else. We work 12 hour shifts and have been practicing Primary Nursing since I started . We care for our patients from diagnosis till remission or comfort care, spanning years, and our patients look for their primary nurses when they are readmitted. We are now embracing Relationship Based Care as our Professional Practice Model with Primary Nursing as our care delivery model. To deliver continuity of care we have Co-Prime pairs and we do our best to mirror each others schedules. We document our plans of care so when we are not on, our co-workers follow and communicate to patients that as well. Our dilema is measurment, our quality indicators have shown high patient satisfaction but we have also been measuring total number of days in 28 day schedule, that the primary pair has cared for their patients. Self scheduling to mirror co-primes has been well received and usually we have 85-90% mirroring when schedule is complete. Post analysis shows we actually only physically care for our primary patients ~ 70-75%. Patient acuity and sick calls, necessity of vacation day are the factors, otherwise when we are on, we care for our primary patients.
Is that a measure we should be concerned about?

6. Rebekah Lindsey - April 22, 2012

My manager is very helpful! Right now we have some staff disatisfaction because some of the time their assignments get changed around due to the coordinator working that shift. Presently, I am feeling pressure from the side of those who do the scheduling, the staff that gets bumped to a different assignment, and the coordinators themselves who weren’t assigned to their primary for one reason or another.

mariemanthey - August 19, 2012

This response is so late, I hope the problem is resolved. With issues like this, the whole key to success is in the ability of people to establish and maintain healthy communication with each other. Sometimes a key group needs to just sit down and figure out how to handle the common situations, and then enroll the support of others to adhere to the guidelines. good luck!

7. Sandy - July 12, 2013

Hello Marie! Not sure if you are still active on this site. I met you in 1980 or there about and recently came across my autographed book “The Practice of Primary Nursing” I am so pleased to see that Primary Nursing continues to be used and grow. Thank you for your work and the work of the nurses when you began spreading the word about Primary Nursing.

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