Advanced Practice Nurses Guiding Families Through Systems

Critical Care Nurse, Vol. 19, No. 5, October 1999

Kate Sullivan Collopy, RN, MSN, CCRN

A challenge faced by advanced practice nurses (APNs) is that they are constantly involved with complex cases and unique situations. These cases often require APNs to guide patients, patients' families, and staff members through complex systems. To do so effectively, APNs require a method that can be applied logically and consistently to a wide variety of patients, families, and situations to plan and provide comprehensive care. The clinical application of the Synergy Model is just such a method.

The Synergy Model is based on the premise that when patients' characteristics are joined with nurses' competencies, optimal outcomes for patients can be achieved. As the model moves from theory into practice, it is helpful to see how nurses in both direct care of patients and advanced practice use the model in day-to-day practice. In this article, I describe how the Synergy Model was used by an APN to assist a family with complex health and psychosocial needs to find safe passage through both the healthcare system and a corporate bureaucracy.

Using The Synergy Model In Advanced Practice


James and Karen Taylor are the parents of quadruplets, born at 32 weeks' gestation. The infant's courses in the neonatal intensive care unit were complicated by repeated episodes of apnea and bradycardia and by severe gastroesophageal reflux. All the infants were discharged at 4 weeks of age with apnea/bradycardia monitors and required multiple medications.

When the quadruplets were 7 months old, they were experiencing, as a group, more than 70 apneic episodes a month. Each child was receiving between 2 and 4 medications (including cisapride (Propulsid), famotidine (Pepcid) and an antacid/antigas agent (Mylanta) requiring a total of 34 separate daily dosings. Pediatric gastroenterologists and ophthalmologists, as well as staff in a high-risk clinic, were providing follow-up to the family.

Because of their premature delivery and resultant medical problems, the quadruplets were at increased risk for infection with respiratory syncytial virus and its subsequent adverse effects. As such, the quadruplets received human immune globulin specific for the virus (Respigam). The parents were also encouraged to reduce the children's risk of exposure to the virus by keeping the infants at home during the season (November to April) for respiratory syncytial virus infections and severely limiting the number of visitors or assistants in the home. Therefore, the Taylors were providing virtually all of the care to their children at home.

In a further complication, the family was notified that Mr. Taylor's employer would be transferring him overseas within 3 months for a 2-year assignment. However, the country to which the family would be relocating lacked the depth and breadth of healthcare and social support resources that the quadruplets required. The Taylors' pediatric specialists cautioned that travel out of the local area while the infants were still using monitors would be hazardous because of the infants' frequent apneic and bradycardic episodes and the need for immediate access to medical facilities. Attempts to defer the work assignment until the children were older and more stable had been unsuccessful.

The parents were referred to the APN for assessment and assistance in supporting their contention that a move overseas could be detrimental to their infants.

Family Assessment


By using the Synergy Model to consider the family as a unit, the APN made the following assessment (Table 1):

  • Resiliency: moderately resilient

    During their persistent apneic and bradycardic episodes, the Taylor infants responded well to tactile and verbal stimulation or brief mouth-to-mouth resuscitation. Their parents were somewhat less resilient. Because of the difficult prenatal course, the children's premature delivery, and subsequent care requirements, the parents' reserves had largely been spent. Mrs. Taylor indicated that she was aware that she and her husband would need to "fight to keep our children at home, where they can get the care they require" while at the same time acknowledging that the parents were "beyond exhausted" and "had nothing left to give."


  • Vulnerability: quite vulnerable

    Because of the children's prematurity and their continuing medical challenges, they were at risk for significant complications, including developmental delays. Because the infants' severe gastroesophageal reflux, meeting their nutritional needs was difficult. All 4 infants were below the fifth percentile in weight. In addition, their prematurity and resultant pulmonary problems left the quadruplets at increased risk for infection with respiratory syncytial virus and its sequelae. Because the parents were caring for their children without respite, the parents were fatigued and overwhelmed. Furthermore, the potential move overseas would leave this family highly vulnerable to a wide array of medical and psychosocial problems due to lack of resources in the new community.


  • Stability: very stable

    The family appeared very stable at this time. Although the children's needs were many and complex, the infants responded well to the various therapies.


  • Complexity: very complex

    The Taylor family was very complex. Within a very short period, Mr. and Mrs. Taylor had to incorporate 4 tiny, fragile premature infants into the fabric of their lives. Feeding, bathing, changing and interacting with 4 healthy newborns is a herculean task. But when each of the newborns has significant medical needs, the responsibilities can be overwhelming.


  • Resource availability: moderate resources

    The Taylor's had moderate resources available. Mr. Taylor's salary was adequate to meet their needs, yet the cost of formula, diapers, medications, therapies, and medical care could quickly overwhelm the family. In terms of psychosocial support, the Taylor's were becoming more and more isolated. From late fall to early spring, their ability to receive assistance from others (families, friends, church members) had to be balanced against the increased risk for exposure of the children to respiratory syncytial virus. If the family were required to move, precious few resources would be available to assist them with the care of their children.


  • Participation in care: full participation

    Mr. and Mrs. Taylor were able to participate fully in the care of their infants.


  • Participation in decision making: high participation

    Although the parents were able to participate fully in decisions about medical care, they appeared to be unable to participate in decisions about where their family would be living and thus about the level of healthcare that would be available.


  • Predictability: moderately predictable

    To some degree, the course that the Taylor quadruplets were likely to follow could be predicted. Often, as children reach 12 months of adjusted age, gastroesophageal reflux abates. Because the Taylor infants were 8 weeks premature, they were expected to reach many of their 12-month-old milestones at 14 months of age. Further, because the apneic and bradycardic episodes were often precipitated by reflux, these issues most likely would also begin to decrease as the problems with reflux were resolved. However, other aspects of their health were far from predictable. Premature, low-birth-weight infants such as multiple birth children are at greater risk for cerebral palsy and developmental delays. Determining which children may go on to have long-term neurological or developmental problems can be exceedingly difficult. The response of Mr. and Mrs. Taylor was more predictable. As the sole caregivers for these infants, they were nearing the point of exhaustion.

Table 1 The Synergy Model: Characteristics of patients
Characteristics and levels Description
Resiliency The capacity to return to a restorative level of functioning by using compensatory/ coping mechanisms; the ability to bounce back quickly after an injury.
Minimal Unable to mount a response; failure of compensatory or coping mechanisms; minimal reserves; brittle.
Moderate Able to mount a moderate response; able to initiate some degree of compensation; moderate reserves.
High Able to mount and maintain a response; intact compensatory or coping mechanisms; strong reserves; endurance.
Vulnerability Susceptibility to actual or potential stressors that may adversely affect patients' outcomes.
High Susceptible; unprotected, fragile.
Moderate Somewhat susceptible; somewhat protected.
Minimal Safe; out of the woods; protected, not fragile.
Stability The ability to maintain a steady-state equilibrium.
Minimal Labile; unstable; unresponsive to therapies; high risk of death.
Moderate Able to maintain steady state for limited period; some responsiveness to therapies.
High Constant; responsive to therapies; low risk of death.
Complexity The intricate entanglement of 2 or more systems (e.g. body, family, therapies).
High Intricate; complex patient/family dynamics; ambiguous or vague; atypical presentation.
Moderate Moderately involved patient/family dynamics.
Minimal Straightforward; routine patient/family dynamics; simple or clear-cut; typical presentation.
Resource Availability Extent of resources (e.g., technical, fiscal, personal, psychological, social) the patient, the patient's family, and the community bring to the situation.
Few Necessary knowledge and skills not available; necessary financial support not available; minimal personal or psychological supportive resources; few social systems resources.
Moderate Limited knowledge and skills available; limited financial support available; limited personal or psychological supportive resources; limited social systems resources.
Many Extensive knowledge and skills available and accessible; financial resources readily available; strong personal or psychological supportive resources; strong social systems resources.
Participation in care Extent to which the patient and the patient's family engage in aspects of care.
None Patient and patient's family unable or unwilling to participate in care.
Moderate Patient and patient's family need assistance in care.
Full Patient and patient's family fully able to participate in care.
Participation in Decision-making
Extent to which patient and patient's family engage in decision-making.
None Patient and patient's family have no capacity for decision-making; require surrogacy.
Moderate Patient and patient's family have limited capacity; seek input and advice from others in decision-making.
Full Patient and patient's family have capacity and make decisions for themselves.
Predictability A summative characteristic that allows one to expect a certain trajectory of illness.
None Uncertain; uncommon population of patients or illness; unusual or unexpected course; does not follow critical pathway, or no critical pathway developed.
Moderate Wavering; occasionally noted population of patients or illness.
High Certain; common population of patients or illness; usual and expected course; follows critical pathway.

APN Activities


By using the Synergy Model, the APN made the following judgments and implemented the following actions with the goal of optimizing outcomes for this family (Table 2).

Clinical Judgment
After this comprehensive assessment, in the APN's judgment, the move proposed by Mr. Taylor's employer would indeed place the entire family at risk for physical and/or psychological harm. The APN's top priority was to delay the move until the children's conditions would safely permit it. Secondary priorities included providing respite care for the parents and ensuring that the children received all necessary developmental evaluations and services.

Clinical Inquiry
The APN was able to provide a variety of research-based resources to support the contention that the children could not be moved at this time. In addition, she was able to present the resources to the parents in such a manner that they could both understand and use the information. Further, the APN coached the parents on how they could use this information to bolster their case with Mr. Taylor's corporation.

Facilitator of Learning
The APN worked with Mr. and Mrs. Taylor to ensure that they understood the likely progression of their children's medical conditions, helped them to anticipate likely events, and worked with them to devise a method to document developmental milestones.

Collaboration and Systems Thinking
The family had already received several letters of support from their own physicians encouraging Mr. Taylor's employer to delay the overseas assignment for 2 years. In addition, through a far-reaching network of colleagues who care for higher order multiple birth children and families, the APN was able to provide additional letters of support from well-known experts in the field. The APN also devised a plan with the Taylor's to navigate through the bureaucracy at Mr. Taylor's corporation. Together, the APN and the parents were able to identify key decision-makers and develop specific strategies to use that would maximize the chance for success with each decision-maker. For example, in dealing with a key financial officer, they emphasized that the decreased quality of healthcare for the infants would result in increased illness, resulting in a drop in Mr. Taylor's productivity and some subsequent degree of loss of revenue for the company.

Advocacy and Moral Agency
The moral imperative in dealing with the Taylor family was to prevent harm from occurring to the infants or the parents. As just illustrated, providing advocacy was a primary intervention in achieving this goal.

Caring Practices
In addition to the healthcare professionals currently working with the Taylor family, the APN recommended that the infants be evaluated by the local early intervention program. Although the children were being followed up by the high-risk clinic, the early intervention program provided additional advantages. Because the evaluations and interventions take place in the family's home, the early intervention specialists see the children in the setting in which the children are most comfortable, enabling a more accurate assessment. Also, the Taylors' local early intervention program provided support services from social workers, staff psychologists and peer counselors, and respite care workers.

Response to Diversity
An important priority too was to ensure that both Mr. Taylor's employer and the Taylors' healthcare professionals recognized and accommodated the Taylor family's unique circumstances as much as possible. This goal was accomplished by coaching the Taylors in ways to clearly articulate their family's needs and expectations. For example, at the high-risk clinic, the nursing staff instructed parents to undress children down to a diaper until the children were examined by the physician. Unfortunately, this practice meant that multiple birth children were often waiting in chilly rooms, clad only in a diaper, as the children's siblings were being examined. The Taylors pointed out that it often took more than an hour for all 4 examinations to be completed. In response, the staff changed their policies to provide warm dressing gowns for children and to allow parents with multiple children to undress 1 child at a time to maintain the children's comfort for as long as possible.

Table 2 The Synergy Model: Characteristics of advanced practice nurses
Characteristic Description
Clinical judgment Synthesize, interpret, and make decisions based on complex, sometimes conflicting, sources of data. Develop, implement, and evaluate research-based algorithms, decision trees, protocols, and care plans for patients and populations of patients. Make expert judgments based on a grasp of the whole picture.
Clinical inquiry (or innovator/evaluator) Formulate, evaluate, and/or revise policies, procedures, protocols, and standards of care. Communicate research results to patients, patients' families, and nursing staff. Model, teach, coach, and/or mentor nursing staff on the use and evaluation of research findings.
Facilitator of learning Develop or refine education programs for patients or populations of patients that are based on patient-driven goals. Facilitate nursing staff development of skills related to patients' education (eg, needs assessment, evaluation of learner understanding, integrating education throughout delivery of care). Create, evaluate, deliver, and coordinate formal and informal staff or interdisciplinary education to improve patients' outcomes and quality of care.
Collaboration Lead or participate in multidisciplinary teams to develop programs focused on issues of patients' care. Initiate collaborative relationships among teams to facilitate interdisciplinary practice. Involve and recruit diverse resources to optimize patients' outcomes (networks).
Systems thinking Develop, integrate, apply, and evaluate a variety of strategies that are driven by the needs and strengths of patient and patients' families, nursing staff, medical staff, and other healthcare professionals. Collaboratively develop and implement research-based and patient-driven systems and processes to improve patients' care. Anticipate possible consequences of changes in systems and develop proactive strategies.
Advocacy and moral agency Establish an environment that promotes ethical decision-making and advocacy for patients. Develop programs to ensure rights of patients and their families (eg, open visitation). Advocate ethical conflicts from the perspective of patients, patients' families, and staff members.
Caring practices Facilitate development of nurses' caring practices through serving as a role model, teaching, coaching, and/or mentoring. Develop and/or implement a process to ensure that the needs of the patient and the patient's family are met in regard to body image, loss, healing, death, and dying or powerlessness. Provide patient and patient's family with skills to navigate transitions along the healthcare continuum (ie, facilitate safe passage).
Response to diversity Tailor the delivery of care, to the extent possible, to meet the diverse needs and strengths of the patient, the patient's family, and staff members. Integrate spiritual and cultural differences and complementary therapies into the care of patients and their families. Recognize issues arising from cultural differences and develop awareness, understanding, and acceptance of these issues with nursing staff, medical staff, and other healthcare professionals.

Outcomes


After several months of negotiations, the Taylors were successful in obtaining a deferment of their overseas transfer for at least 2 years. Indeed, they stated their case so effectively that the corporation has stipulated that any new assignments will take place only on the condition that the quadruplets' health permits such a move.

By the time the children reached 15 months of age, none of them required a monitor. Two children still had residual problems with gastroesophageal reflux, but with substantially decreased severity. After receiving assistance from a speech therapist through the early intervention program, the quadruplets have improved their feeding skills, have begun to gain weight adequately, and now have weights ranging from the 10th to the 25th percentile for their adjusted age. Although their developmental milestones are within normal limits at this time, each of the children will be carefully followed up over the next several years to assess for developmental delays.

In addition to providing play therapy to encourage psychomotor, speech, and social development, the early intervention program also enrolled the Taylors in a respite program, where they receive assistance in caring for their children. Mr. and Mrs. Taylor have also begun to network with other families who have had higher order multiple births. According to the Taylors, this activity has dramatically improved their outlook on life.

Conclusion


The Synergy Model is a user-friendly, highly effective, efficient tool that can be used by novice and experienced APNs in all settings and circumstances. The model helps APNs to recognize problems, anticipate the level of care needed, and avoid potential complications by matching patients' needs with nursing activities.

As illustrated by this case, the Synergy Model can be applied to very complex situations involving multiple patients or family members. In addition, the model helps APNs provide innovative care by clearly mapping out a family's areas of need. As nurses in advanced practice are often called on to deal with the unfamiliar, the model provides a logical starting point from which nurses can move in whatever direction is required. In doing so, comprehensive nursing care can be delivered, needs of patients and patients' families can be met, and outcomes are optimized.

References

1. Curley MAQ. Patient-nurse synergy: optimizing patients' outcomes. Am J Crit Care. 1998;7:64-72.
2. Yokoyama Y, Shimizu T, Hayakawa K. Prevalence of cerebral palsy in twins, triplets and quadruplets. Int J Epidemiol. 1995;24:943-948.
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