The Synergy Model: Linking Patient Needs to Nurse Competencies

Critical Care Nurse, Vol 19, No 1, February 1999
DuAnne Foster Edwards, RN, MN, CS

Several years ago, AACN articulated a vision of a healthcare system driven by patients' needs in which nurses make an optimal contribution. Our focus during the start of managed care was appropriately placed on the patient, and on nurses' relationships with patients. Following this lead, AACN Certification Corporation recognized that the CCRN credential was partially based on an exam shaped by a body systems framework that failed to truly convey the essence of what nurses really did. We needed a better way to talk about patients and nurses' relationships with them. We also needed to focus on what nurses uniquely added to this relationship that helped improve patients' outcomes. Thus, the Synergy Model was described.

The Synergy Model describes patients' characteristics (Table 1) and nurse competencies (Table 2) and notes that when the two are linked, optimal patient outcomes result. Practicing nurses have validated the Synergy Model.

Specifically, acute and critical care nurses believe the following three statements: (1) the Synergy Model's 8 patient characteristics comprehensively and universally describe patient functioning; (2) the Synergy Model's 8 nurse characteristics comprehensively and universally describe contemporary nursing practice; and (3) patient characteristics drive nurse competencies. In addition, the Synergy Model has been presented on numerous occasions to a variety of nursing audiences. It is impressive how nurses overwhelmingly resonate with the model. It illuminates their practice.

Although the Synergy Model has been validated, we need to move it from the theoretical realm into a practical tool that can be used in day-to-day practice. How can we use the Synergy Model to help patients, other members of the patient's team, hospital administrators, and legislators understand what nurses do? One way is to start to use it in at least one aspect of our day-to-day practice. Every day, every shift, charge nurses link patient needs to nurse competencies. We believe the Synergy Model can give charge nurses the words they need to accurately describe the factors that enter into their decision-making process of matching patients to nurses.

The Model in Practice

Assume you're the charge nurse and you're fortunate to have 3 patients and 2 nurses yet to be assigned. First, read through the brief clinical summary of each patient, then try to describe them using the Synergy Model. Note that each patient characteristic occurs on a continuum from high to low; for example, patient stability can range from minimally stable to highly stable.

BOB: 73-year-old male previously highly functional. MVA @ 1800 yesterday, wife of 42 years was killed in the accident. Bob will be told of her death today (he had been told she was being cared for at another hospital). Has 2 children who are here and very supportive. Lethargic and difficult to engage in conversation, but no focal deficits in ER. Had emergency orthopedic procedure on right leg, full recovery anticipated with vigorous physical therapy, etc. Extubated @ 0400 after cleared by anesthesia. Crackles 1/3 way up left side. C/O pleuritic-type chest pain. Lab work normal except Hct dropped from 43% on admission to 35% @ 0600. PMH: noncontributory except for minor hypertension. On lisinopril 20 mg daily.

JUNE: 62-year-old female who is also a diabetic. Admitted on nights with acute lateral wall MI, probably 3 days ago (Troponin I=14 ng/mL, CK negative). Came to ER last night with recurrence of chest pain "like that chest cold I had 3 days ago." No chest pain now. On NTG @ 30 mcg/min and heparin infusion. VS stable, NSR on O2 to keep SpO2 > 92%. Plan for probable catheterization today. Married with 2 grown children living 500 miles away. Husband has extensive health problems (CVA 2 years ago, COPD). Question of compliance in past in regards to diabetes and HTN therapies. Minimal financial resources and health insurance.

BRAD: 20-year-old male college student home for the holidays. Transferred via Med Flight 2 days ago. No PMH. Had upper respiratory infection 3 weeks ago that hung on for about 10 days even with antibiotics prescribed by the University Health Service (unsure of name of medication) Went to local hospital with SOB 23 hours prior to transfer. Antibiotics started for assumed pneumonia. Chest X-ray difficult to interpret, but definite pulmonary edema. Increasing respiratory distress @ transfer led to intubation. Ventilator @ .40 FiO2, A/C of 12, TV of 750 cc. ABGs fair; added 5 cm of PEEP. Pulmonary artery catheter and arterial line placed yesterday. Ventricular filling pressures very high. Started on dobutamine infusion, continuing high dose diuretics frequently. Bedside echocardiogram showed ejection fraction of 15% with diffuse global dysfunction. Liver and renal function deteriorating according to lab. Parents divorced, has 1 sister and 1 brother; all healthy, here and supportive. Had an uncle who had apparent sudden cardiac death @age 46. Work to discuss possible transplant evaluation with patient (though he is sedated) and family today.

Table 1 Patient characteristics

Stability Level 1 Minimally stable Level 3 Moderately stable Level 5 Highly stable The ability to maintain a steady-state equilibrium
Complexity Level 1 Highly complex Level 3 Moderately complex Level 5 Minimally complex The intricate entanglement of two or more systems (e.g. body, family, therapies)
Vulnerability Level 1 Highly vulnerable Level 3 Moderately vulnerable Level 5 Minimally vulnerable Susceptibility to actual or potential stressors that may adversely affect patient outcomes
Resiliency Level 1 Minimally resilient Level 3 Moderately resilient Level 5 Highly resilient The capacity to return to a restorative level of functioning using compensatory coping mechanisms; the ability to bounce back quickly after an insult
Predictability Level 1 Not predictable Level 3 Moderately predictable Level 5 Highly predictable A summative characteristic that allows one to expect a certain trajectory of illness
Resource Availability Level 1 Few resources Level 3 Moderate resources Level 5 Many resources Extent of resources (eg, technical, fiscal, personal, psychological, social) which the patient, family, and community brings to the situation
Participation in care Level 1 No participation Level 3 Moderate level of participation Level 5 Full participation Extent to which the patient and family engages in aspects of care
Participation in decision-making Level 1 No participation Level 3 Moderate level of participation Level 5 Full participation Extent to which the patient and family engages in decision-making

Adapted from: AACN Certification Corporation (1997) Resource Booklet to be used in connection with AACN Certification Corporation Study of Practice Survey Booklet. AACN Certification Corporation, 101 Columbia, Aliso Viejo, CA 92656.

Assessing Patient Characteristics

Let's look at Bob first and decide where he "fits" on the continuum in comparison to an average patient population (realizing that the average patient varies from setting to setting).

Stability: In the terms of ICU acuity, Bob was responsive to therapy and was able to maintain his stability. He would be viewed as moderately to highly stable and close to transferring to an orthopedic unit.

Complexity: Bob is minimally complex from a physiological perspective but moderately complex from a family dynamic perspective.

Resiliency: Due to his age, acute injuries, and surgery, Bob's resiliency may be somewhat decreased. The impact of his spouse's death on his ability to "bounce back", on his motivation, and on his emotional outlook may be profound.

Vulnerability: Bob's fairly good health prior to the accident will make him less vulnerable than similar patients his age. However, due to the factors mentioned under resiliency, he could be more vulnerable.

Predictability: In isolation, Bob's physical progress is highly predictable, but evolving psychosocial and spiritual factors may have a tremendous impact upon his course of illness.

Resource Availability: Bob is on Medicare and has a fixed retirement income. His children are very concerned about him, and are very concerned about him, and are each dealing with the loss of their mother as well. Numerous extended family members and friends have been calling so it appears that Bob has a strong social network to call upon if needed.

Participation in Care: As expected, Bob's children are currently not engaged in his physical care. Nursing staff soon will have to evaluate this further as family participation may be necessary upon Bob's discharge.

Participation in Decision-Making: The family made a decision not to tell Bob about his wife's death when he initially asked. Bob may be angry when he is told. It is anticipated that, as is his usual manner, Bob will be involved from here forward.

Table 2 Nurse characteristics

Clinical judgment Level 1 Competent Level 3 Level 5 Expert 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 experiential knowledge
Advocacy/moral agency Level 1 Competent Level 3 Level 5 Expert Working on another's behalf and representing the concerns of the patient, family and community; serving as a moral agent in identifying and helping to resolve ethical and clinical concerns within the clinical setting
Caring practices Level 1 Competent Level 3 Level 5 Expert The constellation of nursing activities that are responsive to the uniqueness of the patient and family and that create a compassionate and therapeutic environment, with the aim of promoting comfort and preventing suffering. These caring behaviors include, but are not limited to, vigilance, engagement, and responsiveness
Collaboration Level 1 Competent Level 3 Level 5 Expert Working with others, (eg, patients, families and healthcare providers) in a way that promotes and encourages each person's contributions toward achieving optimal and realistic patient goals. Collaboration involves intra-and inter-disciplinary work with all colleagues
Systems thinking Level 1 Competent Level 3 Level 5 Expert The body of knowledge and tools that allows the nurse to appreciate the care environment from a perspective that recognizes the holistic interrelationship that exists within and across healthcare systems
Response to diversity Level 1 Competent Level 3 Level 5 Expert The sensitivity to recognize, appreciate, and incorporate differences into the provision of care. Differences may include, but are not limited to, individuality, cultural differences, spiritual beliefs, gender, race, ethnicity, disability, family configuration, lifestyle, socioeconomic status, age values, ad beliefs surrounding alternative/ complimentary medicine involving patients, families, and members of the healthcare team
Clinical inquiry or innovator/evaluator Level 1 Competent Level 3 Level 5 Expert The ongoing process of questioning and evaluating practice, providing informed practice and innovating through research and experiential learning. The nurse engages in clinical knowledge development to promote the best patient outcomes
Facilitator of learning or patient/ family educator Level 1 Competent Level 3 Level 5 Expert The ability to facilitate patient and family learning

Adapted from: AACN Certification Corporation (1997)I Resource Booklet to be used in connection with AACN Certification Corporation Study of Practice Survey Booklet. AACN Certification Corporation, 101 Columbia, Aliso Viejo, CA 92656.

Determining Nurse Competencies

As the charge nurse making out the assignment, what competencies need to be present in the nurse caring for Bob during the next shift? As indicated, Bob is fairly stable and predictable but vulnerable and potentially lacking resiliency.

Clinical Judgement: The nurse caring for Bob requires at least a competent level of critical thinking/processing and clinical skills. Although Bob is physiologically stable, hopefully his nurse would have experience in helping families deliver bad news to patients, knowing when to lead, and when to provide support and privacy.

Advocacy/Moral Agency: Working on the patient's and family's behalf would be a high priority. The nurse will need to create a mutually supportive environment for the entire family.

Caring Practices: Expert practice is necessary as the nurse will orchestrate a process to ensure Bob's and his family's comfort as they begin to grieve.

Collaboration: A more than competent level of collaborative skill is necessary here because the nurse will be responsible for identifying, initiating, then supporting consultation with numerous supportive services; for example, pastoral care, social services, trauma services, orthopedic services, and physical therapy, etc.

Systems Thinking: This is not an obvious concern unless the patient is in an open bed space and a more private area is available. Anticipating the need for privacy will be especially important in the upcoming shift and may require the nurse to negotiate a bed move. If Bob is still hospitalized during his wife's funeral services, creative planning and negotiation will be necessary.

Response to Diversity: Bob's nurse will have to respond to, anticipate, and integrate personal differences into the patient's and family's care.

Clinical Inquiry: At minimum, the nurse should follow the unit's practice of giving grieving families research-based bereavement materials so adequate follow-up can be initiated.

Facilitator of Learning of Patient/Family: Bob and family undoubtedly will have questions about loss and, at a minimum, the need for orthopedic recovery / plan of care.

Self Evaluation

Did you reach these same general conclusions? Now evaluate the patient characteristics for June and Brad. List the 8 characteristics and select where the patient is on each continuum. Then, select the nurse characteristics / competencies necessary to complement the patient's characteristics. Were your evaluations similar to those reached for Bob? (See Answer key.) Can you prioritize the primary nurse characteristics needed for each patient? Are the patient needs similar or more individual than you had anticipated? Does this process help you identify the best nurse to assign to Bob, June, and Brad?

Answer Key

JUNE
Patient Characteristics
Stability: 4 (cardiac catheterization and acute MI)
Complexity: 3 (DM, HTN, cardiac and social situation)
Vulnerability: 3 (husband's care and cardiac catheterization)
Resiliency: 4 (history)
Predictability: 3
Resource Availability: 1 (financial concerns for medications and hospital coverage; care for husband - will need to investigate area resources, determine children's involvement, etc.)
Participation in Care: 4
Participation in Decision-making: 3 (will need to assess basis for decisions of self-care in past, knowledge base, extended family involvement)
Nurse Characteristics
Clinical Judgement: 3
Advocacy/Moral Agency: 4 (finances, husband's care)
Caring Practices: 4
Collaboration: 4 (finances, individual, social worker, etc.)
Systems Thinker: 4 (Best site for patient - ICU vs. step-down)
Response to Diversity: 3
Clinical Inquiry: 4 (best evidence in managing patients who do not adhere to treatment)
Facilitator of Learning: 5 (see clinical inquiry above)

BRAD
Patient Characteristics
Stability: 1
Complexity: 1
Vulnerability: 2
Resiliency: 3
Predictability: 2
Resource Availability: 5
Participation in Care: 3
Participation in Decision-Making: 2
Nurse Characteristics
Clinical Judgement: 5
Advocacy/Moral Agency: 5
Caring Practices: 4
Collaboration: 5 (transplant evaluation, clinical services)
Systems Thinking: 1
Response to Diversity: 2 (young age, reactions to multi-faceted situation)
Clinical Inquiry: 3
Facilitator of Learning: 4

Hopefully, this exercise has helped you recognize the practical aspects of using the Synergy Model in daily practice. The potential usefulness of the Synergy Model is limitless and can be used as a framework for other nursing activities; for example, nursing orientation, continuing education, and performance evaluation. Each of these applications will be the focus of upcoming articles in this column. Practical, useful models should not be "Ivory Towers." Rather, they should serve as tools to assist us in practice and in articulating what we do.