DNP 805 Module 4 Relationship-Based Care Across a System Example

Carrying a Care Model Across a System: Implementing Relationship-Based Care in Three Community Hospitals

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 805: Organizational and Systems Leadership

Instructor Name

Month Day, Year

Carrying a Care Model Across a System: Implementing Relationship-Based Care in Three Community Hospitals

Care delivery models describe how nursing work is organized: who is responsible for which patients, how relationships with patients and families are built, and how nurses coordinate with each other. The Aspen catalog names relationship-based care among the concerns of systems leadership, because a model that works on one campus does not automatically work on another. This paper examines the implementation of relationship-based care in three community hospitals of a composite health system, after a decade of use at its flagship hospital. It describes the model, reviews the evidence that bears on it, sets out a phased implementation, and identifies how a system nurse leader can adapt the model without losing its core.

The Model

Relationship-based care is a framework for organizing care around three relationships: the nurse's relationship with patients and families, relationships among colleagues, and the nurse's relationship with self, including attention to wellbeing and professional purpose. It is commonly delivered through primary nursing, in which one registered nurse takes responsibility for a patient's care planning and continuity across shifts, with associate nurses following that plan on the primary nurse's days away. The framework also emphasizes shared governance, so that nurses closest to patients help decide how care is organized, and leadership that models the relationships it asks of staff.

The model's appeal lies in continuity. When the same nurse cares for a patient over several days, that nurse notices subtle changes, knows the family's concerns and can coordinate with physicians and therapists more effectively than a nurse meeting the patient for the first time each shift. Patients and families, in turn, know whom to ask. These benefits are intuitive, which is why many hospitals adopt the model, but they depend on staffing patterns that allow continuity to happen.

What the Evidence Shows

Evidence specific to relationship-based care as a named model is limited and largely descriptive, so leaders must rely on evidence about its components. On primary nursing, a systematic review found only five quantitative studies that met its criteria. The primary nursing model was related to nursing-sensitive safety outcomes and to patient satisfaction with nursing care, but research linking it to positive outcomes such as functional status and self-care was scarce, and the authors called for more studies (Gonçalves et al., 2023).

Evidence on the work environment is stronger. In a cross-sectional study of hospitals, a one standard deviation improvement in the nurse work environment score was associated with an 8.1% decrease in the odds of patient mortality, and when work environment and safety climate were modeled together, only the work environment remained significant (Olds et al., 2017). Relationship-based care aims to improve precisely the relational and organizational features, such as collegial relationships, nurse participation in decisions and leadership support, that make up a good work environment. Leadership evidence points the same way: relational leadership styles are consistently linked with better nurse satisfaction, retention and working conditions (Cummings et al., 2018).

The Implementation Challenge

The three community hospitals differ from the flagship. Two use team nursing, with licensed practical nurses and assistants caring for patients under a registered nurse's direction; one relies heavily on travel nurses; and all three have more patients per registered nurse at night. Primary nursing, in its full form, requires stable registered nurse staffing and consistent assignments, which these hospitals cannot immediately provide. Imposing the flagship's model unchanged would likely produce a name without the practice.

Culture differs as well. The flagship hospital's nurses have worked within the model long enough that its language is familiar and its expectations are taken for granted. At the community hospitals, some nurses see relationship-based care as a corporate program arriving with the new owner, and others fear it will add documentation without adding staff. A leader who ignores these perceptions will meet quiet resistance, however sound the model.

A Phased Implementation

The system chief nursing officer proposes three phases over 18 months. In the first phase, each hospital forms a shared governance council and a design team of frontline nurses, who visit the flagship hospital, learn the model and assess their own units. The focus is on relationships among colleagues and with self, through staff meetings on purpose and values and a program on nurse wellbeing, because these require no staffing change. In the second phase, units adopt consistent assignment, keeping nurses with the same patients across consecutive shifts wherever possible, and daily care conversations with patients and families about goals. In the third phase, units that have achieved stable staffing adopt primary nursing, while units that use team nursing adapt it, designating a registered nurse as accountable for each patient's plan throughout the stay.

Throughout, the system tracks consistent assignment rates, nurse turnover and engagement, patient experience scores on nurse communication, and nursing-sensitive outcomes such as falls and pressure injuries, reporting results to each hospital's council.

Resources accompany each phase. The system funds release time for design team members, a part-time implementation coach at each hospital drawn from the flagship's experienced nurses, and the scheduling changes needed for consistent assignment. Without these, the phases would ask nurses to redesign their work on top of full assignments, which is the most common reason care model changes stall.

Adapting Without Losing the Core

The leadership task is to distinguish the model's core from its form. The core is that each patient has a nurse who knows them and is accountable for their plan, that nurses work in respectful relationships with each other, and that nurses have a voice in how care is organized. The form, whether primary nursing or an accountable nurse within a team, can vary with staffing. Allowing variation in form while holding the core constant respects each hospital's reality and makes the model more likely to last.

Conclusion

Extending relationship-based care from a flagship hospital to community hospitals is a test of systems leadership. Direct evidence for the model is limited, but evidence on primary nursing, work environments and relational leadership supports its components. A phased implementation that begins with relationships and governance, then consistent assignment, then accountable nursing adapted to staffing, allows each hospital to adopt the model's core without copying a form it cannot sustain.

References

Cummings, G. G., Tate, K., Lee, S., Wong, C. A., Paananen, T., Micaroni, S. P. M., & Chatterjee, G. E. (2018). Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. International Journal of Nursing Studies, 85, 19-60. https://doi.org/10.1016/j.ijnurstu.2018.04.016

Gonçalves, I., Mendes, D. A., Caldeira, S., Jesus, É., & Nunes, E. (2023). The primary nursing care model and inpatients' nursing-sensitive outcomes: A systematic review and narrative synthesis of quantitative studies. International Journal of Environmental Research and Public Health, 20(3), Article 2391. https://doi.org/10.3390/ijerph20032391

Olds, D. M., Aiken, L. H., Cimiotti, J. P., & Lake, E. T. (2017). Association of nurse work environment and safety climate on patient mortality: A cross-sectional study. International Journal of Nursing Studies, 74, 155-161. https://doi.org/10.1016/j.ijnurstu.2017.06.004