Applying the Synergy Model: Clinical Strategies

Critical Care Nurse, Vol 21, No. 3, June 2001

Donna W. Markey , MSN, RN-CS, ACNP

The Synergy Model describes a framework for nursing practice. Its hallmark is the linkage of patient characteristics with nurse competencies to achieve optimal patient outcomes.(1) Throughout time, nurses have made unique contributions to patient outcomes. We have often fallen short in describing or characterizing these contributions or giving appropriate credit to the significant and essential role nurses play in the healthcare system. In our current healthcare environment, a shrinking nursing workforce and increased consideration to expanding roles for non-nurse caregivers are a call to our profession to account for the varied and unique contributions nurses bring to optimizing patient outcomes. One method of articulating these contributions is the descriptive use of clinical exemplars. Patricia Benner 2 popularized the use of exemplars to capture the interpretive details of expert nursing practice development while researching the application of the Dreyfus Model of Skill Acquisition to clinical nursing practice. The American Association of Critical-Care Nurses Certification Corporation proposes the Synergy Model as a blueprint for the certification of acute and critical care nurses; however, the model offers much broader implications to us as we seek to describe the essence and benefits of expert nursing practice in relation to our patients' needs and their subsequent outcomes. The following is one such example.

June's Story


June had undergone resection of a large retroperitoneal sarcoma, distal pancreatectomy, and splenectomy 3 weeks before her current hospitalization. Following a fairly routine postoperative course she had been discharged home. After being home a few days she called me through the hospital operator one Sunday afternoon because she was having trouble with gas. She described her abdomen as being bloated and uncomfortable. She had eaten but had "spit up" part of her breakfast. She was keeping liquids down and had had a bowel movement the day before. I advised her to report to the emergency department (ED) where she could be appropriately evaluated. I told her that I would call ahead and speak with our in-house resident. She wished to avoid returning to the hospital and asked if there was anything else she could do. We discussed taking something for the gas and limiting her intake to liquids only. I instructed her to report to the ED if she had any episodes of vomiting overnight. I would otherwise plan to see her in the office first thing the next morning. She assured me she would go to the ED if she felt worse.

June presented to the ED at her family's insistence that evening. She had an episode of vomiting and worsening abdominal pain and distention. It was determined that she had a partial small bowel obstruction by abdominal radiograph. She was admitted for nasogastric tube decompression of the stomach, intravenous (IV) hydration, and electrolyte replacement.

June was well-known to me. I first met her when her local surgeon referred her to our surgical oncology group with a tumor that he determined to be beyond his surgical skill level for resection. I participated in her initial surgical evaluation and preparation, at which time it was discovered she had a deep vein thrombosis necessitating 8 weeks of oral anticoagulation therapy before the resection of her retroperitoneal mass could be attempted. During this time, through several office visits and telephone conversations, I got to know June and her husband quite well. I was responsible for her perioperative care coordination throughout the 8 weeks of anticoagulation therapy. I would continue to coordinate her care through this admission.

June was an active 63-year-old woman. She was the family matriarch: a mother, grandmother, and wife. She was an avid gardener who hoped to be well to plant her spring flowers. She was kind and very sweet and never complained; she did not want to be a burden to anyone. This knowledge of her personality was vitally important to understanding June and her response to her illness.

On June's third hospital day, her daily flow sheet revealed that her blood pressure was 88/60 mm Hg; pulse, 120 beats per minute; and oral temperature, 36.7 degrees C. Her urine output had been 150 mL for the previous 8 hours, just less than 20 mL/h. She had received a fluid bolus of 1 L isotonic sodium chloride overnight and had not voided. She was finishing a second liter bolus of isotonic sodium chloride as I entered the room. Her maintenance IV was infusing at 75 mL/h. Her systolic blood pressure had risen slightly to 100 mm Hg. She was in bed, lying on her side, looking uncomfortable and slightly ashen. She had a nasogastric tube and a peripheral IV catheter. Although June said that she had slept well and that she felt more rested, she expressed concern regarding her systolic blood pressure, which typically was about 130 mm Hg (June routinely asked about the reading of her blood pressure).

I examined her abdomen and found that it was hard, largely distended, and very hot to the touch. By comparison, her extremities, chest, and forehead were cool. I asked her if her belly hurt and she said no. Upon palpation of the abdomen, she jumped as if a shock ran through her. "June, did that hurt you?" "Oh no," she said, "it's just that you are messing with it." She was guarded through the rest of my examination. I had last examined her roughly 15 hours earlier. My findings on this examination were quite different. The character of her nasogastric drainage had also changed; the effluent was dark brown in large amounts, in contrast to green bilious drainage of limited amounts the day before.

Her nurse, Jeff, was clearly concerned about her fluid status and blood pressure. The heat emanating from her abdomen particularly struck me. He had not noticed that earlier, but after examining her again he too felt that her abdomen was tighter and more distended than it had been earlier. It felt hot to him, which he did not remember from his earlier examination.

June's changing abdominal examination, together with hypotension and low urine output, concerned me. I suspected that she was evolving a full bowel obstruction, possible perforation, sepsis, or abdominal compartment syndrome resulting from the massive swelling in her abdomen. The heat of her abdomen signified a localized inflammatory process. Based on her stoic response to previous surgery, I suspected that her current denial of pain was less than reliable. In addition, it was inconsistent with the tenderness elicited to palpation of her abdomen.

Jeff had received a written order from the intern that morning for an enema with a suppository to follow if the enema did not work. He had not yet administered it and asked me if he should or not. I said that under no circumstances should he consider giving this patient an enema and suppository. In some instances of resolving partial small bowel obstruction a suppository or enema may be appropriate. However, this was no longer June's diagnosis - she was likely to be completely obstructed. An enema could cause significant damage such as a bowel perforation.

Jeff called the intern to report another decrease in the blood pressure, to 88/40 mm Hg, and that June had not had a response to the latest bolus of isotonic sodium chloride. He also reported our abdominal examination findings, including how hot her abdomen felt. The intern ordered a third liter of fluid, but seemed to dismiss Jeff's concerns regarding June's abdominal examination. I then contacted the senior resident and described my current clinical findings - including vital signs, fluid status, and low urine output - and grave concern that June's condition was deteriorating. I described her denial of pain in contrast to her actual response to my examination, and reminded him of the very high pain tolerance she demonstrated after her initial surgery. I told him I had interceded the earlier orders for the enema and suppository. I also told him that I believed June had an acute abdomen and needed emergent surgery. He thanked me for the call and said that he would come see her within 20 minutes.

June's attending surgeon was involved in a long operative case and was not immediately available. If the chief resident had not responded as he did I would have gone to the operating room to speak directly with the surgeon, because this was clearly an emergent situation.

June was growing aware of the gravity of her situation; the discomfort and abdominal distention were becoming undeniable to her. When I reentered her room she asked me if I thought she would need an operation to fix this. I explained that scar tissue had probably caused a portion of the bowel to kink or twist on itself. I told her that the resident in charge was coming to examine her and that he would discuss June's options with her and her surgeon, and that together they would make a plan. She said, "I trust you to do the right thing for me." I asked if she wanted me to notify her husband, and she said no because she was expecting him and her sister soon. I had spoken with her sister earlier and conveyed concern about June's abdomen explaining that I anticipated that she would be requiring further surgery. I updated Jeff as to the plan and my suspicions. He began work on the necessary preoperative preparations, hung another liter of normal saline, and increased the maintenance IV to 125 mL/h. June finally voided approximately 50 mL of very concentrated urine. She would need a Foley catheter.

June's blood pressure rose to 102/70 mm Hg and the resident was en route. I had a commitment, and had to explain to June that I would be back in approximately 2 hours. When I returned 1.5 hours later June was in surgery.

Patient Characteristics

The Synergy Model describes patient characteristics (Table 1) that span the continuum of health and illness. Each characteristic exists on its own continuum. For example, June's condition changed over several hours from being stable to unstable. These characteristics help us recognize each patient's capacities for health and vulnerabilities to illness. Understanding these characteristics and how they can fluctuate with a patient's condition or situation helps us to recognize the essential nurse competencies that together synergize to result in optimal patient outcomes.

June's condition was decreasing in stability and increasing in complexity. She was unable to maintain steady-state equilibrium due to the complexity of multiorgan system imbalance as her clinical condition deteriorated. The trajectory of her illness was no longer predictable as it had been during her initial surgical admission. The only thing I could predict was that she would continue to deteriorate without surgical intervention. June's resilience was very limited in her condition, her capacity to return to a restorative level of functioning would hinge on the outcome of surgery, which was difficult to predict. June's vulnerability was extremely high, the physical and psychological stressors she was facing had the potential to result in a devastating outcome. June remained an active participant in decision-making in all aspects of her care. She chose to proceed with the initial surgery fully informed of the risks she faced in having such a large tumor resected from her abdomen. In this emergent situation, she realized that surgery was her "only option," and it remained her choice. Her family arrived at the hospital in time to support her in this decision. Throughout her illness, June had strong support from her family, friends, and church community. She had adequate personal, psychological, social, and financial resource availability.

Table 1 Patient characteristics
Stability
Ability to maintain equilibrium
Complexity
Entanglement of 2 or more systems (body, family, therapies)
Predictability
Summative patient characteristics implying a certain illness trajectory
Resiliency
Restorative capacity via compensatory and coping mechanisms
Vulnerability
Susceptibility to actual or potential stressors adversely affecting outcomes
Participation in decision-making and care
Patient and family engagement in decision-making and care processes
Resource availability
Personal, psychological, social, technical, and fiscal resources the patient, family, or community bring to a care situation
Adapted from Curley M.(1)

Nurses' Competencies


Nursing competencies, like patient characteristics, exist along a continuum. The Synergy Model describes 8 competencies that are essential for contemporary nursing practice (Table 2). Each competency assumes a higher or lower degree of importance in each individual patient situation. The competencies most significant in June's situation were clinical judgment, advocacy, moral agency, caring practices, facilitation of learning, and collaboration.

My clinical judgment is built upon a foundation of 20 years experience with surgical and critical care patients coupled with advanced educational preparation and specialty certification at the postgraduate level. The application of this knowledge and experience allowed me to rapidly assess and intervene in June's care to ensure appropriate attention to changes in her clinical condition. These early subtle changes may have been minimized or overlooked by less experienced clinicians.

This surgical scenario called for a high degree of advocacy and moral agency. Advocacy on behalf of a patient can result in the appropriate, timely delivery of care, the avoidance of harm, and prevention of adverse events. Effective advocacy requires skills of communication and conviction. Conviction in my knowledge, assessment skills, and instincts together with effective communication skills enabled me to serve as June's advocate and moral agent. As her moral agent, I provided leadership in determining and helping to resolve the clinical concerns presented by June's deteriorating condition.

Together, the staff nurse (Jeff) and I provided caring practices for June. We were highly responsive to her unique and changing needs. We acted together to ensure her safety and comfort. Our vigilance and responsiveness to her needs engendered her trust in us. The facilitation of learning competency was more appropriately directed toward Jeff in this situation. His questions and concerns reflected his awareness of June's declining condition; he was struggling with some pieces of the clinical puzzle and associated issues of relating his concerns to the staff. My knowledge and experience were valuable resources to him in learning how to manage this situation.

The complex nature of patient care today demands a collaborative approach to problem solving and care delivery. This collaboration is generally both intradisciplinary and interdisciplinary. Jeff and I effectively collaborated to deliver care to meet June's needs, we were challenged in our efforts to collaborate with our physician colleagues. Collaboration in such a situation may require effective persuasion and negotiation skills in addition to the more straightforward aspects of communication and relationship development. All parties need to be invested in the outcome for collaboration to be feasible and meaningful.

Response to diversity is an essential competency that is growing in recognition in our healthcare culture. June did not really pose any unique challenges in this regard. Her beliefs, values, and family configuration were quite traditional.

Table 2 Nurse Competencies
Clinical judgment
Use clinical reasoning including decision-making, critical thinking, and global grasp of the situation coupled with acquired formal and experiential knowledge and skills.
Advocacy and moral agency
Work on another's behalf; represent the concerns of patients and their families; and assume a leadership role in addressing ethical and clinical concerns.
Caring practices
Create a compassionate and therapeutic environment driven by the unique needs of the patient - includes vigilance, engagement, and responsiveness.
Facilitator of learning
Use of self to facilitate learning.
Collaboration
Facilitate each person's contribution toward achieving optimal or realistic goals for the patient - involves intradisciplinary and interdisciplinary work with colleagues.
Systems thinking
Recognize the holistic interrelationships that exist in and across the healthcare system in the context of the care environment.
Response to diversity
Recognize differences and incorporate them in the provision of care.
Clinical inquiry
Engage in the ongoing process of questioning and evaluating practice, providing evidence-based practice and innovating through research and experiential learning. Use clinical knowledge development to promote the best outcomes for patients.

Adapted from Curley, M.(1)

Outcomes


The overarching outcome in this clinical scenario was to see to June's safety and comfort and in so doing, to see that she received the appropriate level of care. As her condition changed and clinical course deteriorated the goal became seeing her safely to surgery. This was achieved in a caring and therapeutic environment. June's trust and confidence in her caregivers, the foundation of our relationship, were essential components of ensuring her safe passage. Fidelity to this patient is demonstrated in the strong patient advocacy posture necessary between advanced practice nurses and physicians in training. To achieve the best outcome for this patient, it was necessary for me to be assertive, confident, persistent, and convincing.

Conclusion


June's story captures the synergy possible between patient and nurse when patient needs and characteristics drive the application of nurse competencies. The Synergy Model describes 7 characteristics of patients that are common concerns to nurses. It links these characteristics with 8 nurse competencies that are of importance to patients. The complexity of this patient's characteristics and problems required the interplay of each of these nurse competencies to ensure a sage outcome for this patient. In our complex healthcare environment with increased patient acuity and advancing technology, it is essential that nurses with these competencies are available to ensure safe passage for patients.

References


1. Curley MAQ. Patient-nurse synergy: optimizing patients' outcomes. Am J Crit Care. 1998;7:64-72.
2. Benner P. From Novice to Expert. Menlo Park, Calif: Addison-Wesley; 1984.

Donna W. Markey is a clinician IV at Digestive Health Services, University of Virginia, Charlottesville, VA.
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