The AACN Synergy Model for Patient Care

Basic Information About the AACN Synergy Model for Patient Care

The core concept of the reconceptualized model of certified practice — the AACN Synergy Model for Patient Care — is that the needs or characteristics of patients and families influence and drive the characteristics or competencies of nurses. Synergy results when the needs and characteristics of a patient, clinical unit or system are matched with a nurse's competencies.

All patients have similar needs and experience these needs across wide ranges or continuums from health to illness. Logically, the more compromised patients are, the more severe or complex are their needs. The dimensions of a nurse's practice are driven by the needs of a patient and family.

This requires nurses to be proficient in the multiple dimensions of the nursing continuum. When nurse competencies stem from patient needs and the characteristics of the nurse and patient synergize, optimal patient outcomes can result.

The AACN Synergy Model and Certification Exams

The AACN Synergy Model for Patient Care was developed to link clinical practice with patient outcomes. The integration of the Synergy Model into AACN Certification Corporation credentialing programs puts an emphasis on the patient, and says to the world that patients come first. Nurses make a unique contribution to outcomes, quality of care and containment of costs.

Recognizing the additional components that comprise critical care nursing, 20% of the CCRN exam is based on the components of Advocacy/Moral Agency, Caring Practices, Collaboration, Systems Thinking, Response to Diversity, Clinical Inquiry and Facilitation of Learning. These nursing characteristics are referred to collectively as "Professional Caring and Ethical Practice." The remaining 80% of the CCRN exam is based on Clinical Judgment.

Since July 1, 1999, the CCRN exam has included the Professional Caring and Ethical Practice component, which is based on the AACN Synergy Model for Patient Care. Prior to the application of the Synergy Model framework to the CCRN certification program, the exam was based solely on Clinical Judgment.

The Synergy Model — and its incorporation into all AACN specialty certification exams — is not to have nurses memorize the various patient or nurse characteristics or their levels. They are presented here to help you begin to comprehend the model. Test questions cover application of the Synergy Model, not its terminology.

Basic Information About the Synergy Model
Patient Characteristics
Nurse Characteristics
Assumptions Guiding the Synergy Model

Characteristics of Patients, Clinical Units and Systems of Concern to Nurses

Each patient and family, clinical unit and system is unique, with a varying capacity for health and vulnerability to illness. Each one brings a set of unique characteristics to the care situation. These characteristics span the health-illness continuum.

Resiliency The capacity to return to a restorative level of functioning using compensatory/coping mechanisms; the ability to bounce back quickly after an insult
Level 1 - Minimally resilient Unable to mount a response; failure of compensatory/coping mechanisms; minimal reserves; brittle
Level 3 - Moderately resilient Able to mount a moderate response; able to initiate some degree of compensation; moderate reserves
Level 5 - Highly resilient Able to mount and maintain a response; intact compensatory/coping mechanisms; strong reserves; endurance
Vulnerability Susceptibility to actual or potential stressors that may adversely affect patient outcomes
Level 1 - Highly vulnerable Susceptible; unprotected, fragile
Level 3 - Moderately vulnerable Somewhat susceptible; somewhat protected
Level 5 - Minimally vulnerable Safe; out of the woods; protected, not fragile
Stability The ability to maintain a steady-state equilibrium.
Level 1 - Minimally stable Labile; unstable; unresponsive to therapies; high risk of death
Level 3 - Moderately stable Able to maintain steady state for limited period of time; some responsiveness to therapies
Level 5 - Highly stable Constant; responsive to therapies; low risk of death
Complexity The intricate entanglement of two or more systems (e.g., body, family, therapies)
Level 1 - Highly complex Intricate; complex patient/family dynamics; ambiguous/vague; atypical presentation
Level 3 - Moderately complex Moderately involved patient/family dynamics
Level 5 - Minimally complex Straightforward; routine patient/family dynamics; simple/clear cut; typical presentation
Resource availability Extent of resources (e.g., technical, fiscal, personal, psychological and social) the patient/family/community bring to the situation
Level 1 - Few resources Necessary knowledge and skills not available; necessary financial support not available; minimal personal/psychological supportive resources; few social systems resources
Level 3 - Moderate resources Limited knowledge and skills available; limited financial support available; limited personal/psychological supportive resources; limited social systems resources
Level 5 - Many resources Extensive knowledge and skills available and accessible; financial resources readily available; strong personal/psychological supportive resources; strong social systems resources
Participation in care Extent to which patient/family engages in aspects of care
Level 1 - No participation Patient and family unable or unwilling to participate in care
Level 3 - Moderate level of participation Patient and family need assistance in care
Level 5 - Full participation Patient and family fully able to participate in care
Participation in decision-making Extent to which patient/family engages in decision-making
Level 1 - No participation Patient and family have no capacity for decision-making; requires surrogacy
Level 3 - Moderate level of participation Patient and family have limited capacity; seeks input/advice from others in decision-making
Level 5 - Full participation Patient and family have capacity, and makes decision for self
Predictability A characteristic that allows one to expect a certain course of events or course of illness
Level 1 - Not predictable Uncertain; uncommon patient population/illness; unusual or unexpected course; does not follow critical pathway, or no critical pathway developed
Level 3 - Moderately predictable Wavering; occasionally noted patient population/illness
Level 5 - Highly predictable Certain; common patient population/illness; usual and expected course; follows critical pathway
For example:

A healthy, uninsured, 40-year-old woman undergoing a pre-employment physical is likely to be: (a) stable (b) not complex (c) very predictable (d) resilient (e) not vulnerable (f) able to participate in decision-making and care, but (g) has inadequate resource availability.

A critically ill infant with multisystem organ failure is likely to be: (a) unstable (b) highly complex (c) unpredictable (d) highly resilient (e) vulnerable (f) unable to become involved in decision-making and care, but (g) has adequate resource availability.

Basic Information About the Synergy Model
Patient Characteristics
Nurse Characteristics
Assumptions Guiding the Synergy Model

Nurse Competencies of Concern to Patients, Clinical Units and Systems

Nursing care reflects an integration of knowledge, skills, experience and attitudes needed to meet the needs of patients and families. Thus, continuums of nurse characteristics are derived from patient needs. The following are levels of expertise ranging from competent (1) to expert (5):

Clinical Judgment Clinical reasoning, which includes clinical decision-making, critical thinking and a global grasp of the situation, coupled with nursing skills acquired through a process of integrating formal and informal experiential knowledge and evidence-based guidelines
Level 1 Collects basic-level data; follows algorithms, decision trees and protocols with all populations and is uncomfortable deviating from them; matches formal knowledge with clinical events to make decisions; questions the limits of one's ability to make clinical decisions and delegates the decision-making to other clinicians; includes extraneous detail
Level 3 Collects and interprets complex patient data; makes clinical judgments based on an immediate grasp of the whole picture for common or routine patient populations; recognizes patterns and trends that may predict the direction of illness; recognizes limits and seeks appropriate help; focuses on key elements of case, while sorting out extraneous details
Level 5

Synthesizes and interprets multiple, sometimes conflicting, sources of data; makes judgment based on an immediate grasp of the whole picture, unless working with new patient populations; uses past experiences to anticipate problems; helps patient and family see the "big picture"; recognizes the limits of clinical judgment and seeks multidisciplinary collaboration and consultation with comfort; recognizes and responds to the dynamic situation

Advocacy and Moral Agency

Working on another's behalf and representing the concerns of the patient/family and nursing staff; serving as a moral agent in identifying and helping to resolve ethical and clinical concerns within and outside the clinical setting

Level 1 Works on behalf of patient; self assesses personal values; aware of ethical conflicts/issues that may surface in clinical setting; makes ethical/moral decisions based on rules; represents patient when patient cannot represent self; aware of patients' rights
Level 3 Works on behalf of patient and family; considers patient values and incorporates in care, even when differing from personal values; supports colleagues in ethical and clinical issues; moral decision-making can deviate from rules; demonstrates give and take with patient's family, allowing them to speak/represent themselves when possible; aware of patient and family rights
Level 5

Works on behalf of patient, family and community; advocates from patient/family perspective, whether similar to or different from personal values; advocates ethical conflict and issues from patient/family perspective; suspends rules - patient and family drive moral decision-making; empowers the patient and family to speak for/represent themselves; achieves mutuality within patient/professional relationships

Caring Practices Nursing activities that create a compassionate, supportive and therapeutic environment for patients and staff, with the aim of promoting comfort and healing and preventing unnecessary suffering. Includes, but is not limited to, vigilance, engagement and responsiveness of caregivers, including family and healthcare personnel.
Level 1 Focuses on the usual and customary needs of the patient; no anticipation of future needs; bases care on standards and protocols; maintains a safe physical environment; acknowledges death as a potential outcome
Level 3 Responds to subtle patient and family changes; engages with the patient as a unique patient in a compassionate manner; recognizes and tailors caring practices to the individuality of patient and family; domesticates the patient's and family's environment; recognizes that death may be an acceptable outcome
Level 5 Has astute awareness and anticipates patient and family changes and needs; fully engaged with and sensing how to stand alongside the patient, family and community; caring practices follow the patient and family lead; anticipates hazards and avoids them, and promotes safety throughout patient's and family's transitions along the healthcare continuum; orchestrates the process that ensures patient's/family's comfort and concerns surrounding issues of death and dying are met
Collaboration Working with others (e.g., patients, families, healthcare providers) in a way that promotes/encourages each person's contributions toward achieving optimal/realistic patient/family goals; involves intra- and inter-disciplinary work with colleagues and community
Level 1 Willing to be taught, coached and/or mentored; participates in team meetings and discussions regarding patient care and/or practice issues; open to various team members' contributions
Level 3 Seeks opportunities to be taught, coached and/or mentored; elicits others' advice and perspectives; initiates and participates in team meetings and discussions regarding patient care and/or practice issues; recognizes and suggests various team members' participation
Level 5 Seeks opportunities to teach, coach and mentor and to be taught, coached and mentored; facilitates active involvement and complementary contributions of others in team meetings and discussions regarding patient care and/or practice issues; involves/recruits diverse resources when appropriate to optimize patient outcomes
Systems Thinking Body of knowledge and tools that allow the nurse to manage whatever environmental and system resources exist for the patient/family and staff, within or across healthcare and non-healthcare systems.
Level 1 Uses a limited array of strategies; limited outlook - sees the pieces or components; does not recognize negotiation as an alternative; sees patient and family within the isolated environment of the unit; sees self as key resource
Level 3

Develops strategies based on needs and strengths of patient/family; able to make connections within components; sees opportunity to negotiate, but may not have strategies; developing a view of the patient/family transition process; recognizes how to obtain resources beyond self

Level 5 Develops, integrates and applies a variety of strategies that are driven by the needs and strengths of the patient/family; global or holistic outlook - sees the whole rather than the pieces; knows when and how to negotiate and navigate through the system on behalf of patients and families; anticipates needs of patients and families as they move through the healthcare system; utilizes untapped and alternative resources as necessary
Response to Diversity The sensitivity to recognize, appreciate and incorporate differences into the provision of care; differences may include, but are not limited to, cultural differences, spiritual beliefs, gender, race, ethnicity, lifestyle, socioeconomic status, age and values
Level 1 Assesses cultural diversity; provides care based on own belief system; learns the culture of the healthcare environment
Level 3 Inquires about cultural differences and considers their impact on care; accommodates personal and professional differences in the plan of care; helps patient/family understand the culture of the healthcare system
Level 5 Responds to, anticipates and integrates cultural differences into patient/family care; appreciates and incorporates differences, including alternative therapies, into care; tailors healthcare culture, to the extent possible, to meet the diverse needs and strengths of the patient/family
Facilitation of Learning The ability to facilitate learning for patients/families, nursing staff, other members of the healthcare team and community; includes both formal and informal facilitation of learning
Level 1 Follows planned educational programs; sees patient/family education as a separate task from delivery of care; provides data without seeking to assess patient's readiness or understanding; has limited knowledge of the totality of the educational needs; focuses on a nurse's perspective; sees the patient as a passive recipient
Level 3 Adapts planned educational programs; begins to recognize and integrate different ways of teaching into delivery of care; incorporates patient's understanding into practice; sees the overlapping of educational plans from different healthcare providers' perspectives; begins to see the patient as having input into goals; begins to see individualism
Level 5 Creatively modifies or develops patient/family education programs; integrates patient/family education throughout delivery of care; evaluates patient's understanding by observing behavior changes related to learning; is able to collaborate and incorporate all healthcare providers' and educational plans into the patient/family educational program; sets patient-driven goals for education; sees patient/family as having choices and consequences that are negotiated in relation to education
Clinical Inquiry (Innovator/Evaluator) The ongoing process of questioning and evaluating practice and providing informed practice; creating practice changes through research utilization and experiential learning
Level 1 Follows standards and guidelines; implements clinical changes and research-based practices developed by others; recognizes the need for further learning to improve patient care; recognizes obvious changing patient situation (e.g., deterioration, crisis); needs and seeks help to identify patient problem
Level 3 Questions appropriateness of policies and guidelines; questions current practice; seeks advice, resources or information to improve patient care; begins to compare and contrast possible alternatives
Level 5 Improves, deviates from or individualizes standards and guidelines for particular patient situations or populations; questions and/or evaluates current practice based on patients' responses, review of the literature, research and education/learning; acquires knowledge and skills needed to address questions arising in practice and improve patient care; (The domains of clinical judgment and clinical inquiry converge at the expert level; they cannot be separated)
For example:

If the patient were stable but unpredictable, minimally resilient and vulnerable, primary competencies of the nurse would be centered on clinical judgment and caring practices, (which includes vigilance).

If the patient were vulnerable, unable to participate in decision-making and care and inadequate resource availability, the primary competencies of the nurse would focus on advocacy and moral agency, collaboration and systems thinking.

All eight competencies are essential for contemporary nursing practice, but each assumes more or less importance depending on a patient's characteristics. Synergy results when the needs and characteristics of a patient, clinical unit or system are matched with a nurse's competencies.

Basic Information About the Synergy Model
Patient Characteristics
Nurse Characteristics
Assumptions Guiding the Synergy Model

Assumptions Guiding the AACN Synergy Model for Patient Care

These characteristics must be viewed in context. Various assumptions regarding nurses, patients and families guide the Synergy Model:

  • Patients are biological, psychological, social and spiritual entities who present at a particular developmental stage.
    • The whole patient (body, mind and spirit) must be considered.
  • The patient, family and community all contribute to providing a context for the nurse-patient relationship.
  • Patients can be described by a number of characteristics.
    • All characteristics are connected and contribute to each other.
    • Characteristics cannot be looked at in isolation.
  • Similarly, nurses can be described on a number of dimensions.
    • The interrelated dimensions paint a profile of the nurse.
  • A goal of nursing is to restore a patient to an optimal level of wellness as defined by the patient.
    • Death can be an acceptable outcome, in which the goal of nursing care is to move a patient toward a peaceful death.

For further practice determining patient needs and matching them to nurse competencies, view copies of The Synergy Model in Practice column from Critical Care Nurse.

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