Being A Good Dance Partner
Critical Care Nurse, Vol. 19, No. 6, December 1999
The historical conceptualization of nursing, namely, one that
defines clinical practice by the nurse's role, the clinical setting, and the
patient's diagnosis, is of limited usefulness in today's healthcare climate
because it overlooks the unique needs and characteristics of patients and their
families as the driving force behind nursing practice. In response to the evolving
healthcare system, the AACN Certification Corporation designed a model that describes
nursing practice on the basis of the needs and characteristics of patients and their
families. The core concept behind this model, which is called the Synergy Model,
is that the unique needs or characteristics of patients and their families influence
and drive the characteristics or competencies of nurses. According to the model,
optimal outcomes for patients occur when patients' and nurses' characteristics
are matched. Matching the needs and characteristics of a particular patient and
his or her family with those of the nurse creates synergy, in which the cooperative
activity of 2 or more agents or persons yields a result that is greater than the
combined result would have been if each had worked alone.
Recent research on critical care nurses' interventions
and interactions with families of critically ill adults indicates that all nurses
and all patients' families bring with them to the situation their habits, practices,
concerns, and skills. This combination of factors can be thought of as a person's
stance. A nurse's stance makes certain activities and interventions possible
and determines, in part, how successful the nurse-family interaction is. In this
way, interactions between nurses and patients' families can be thought of as
a dance. Engaged and skillful dance partners take cues from each other and respond
appropriately by altering tone, tempo, and movements, resulting in smooth and coordinated
dance steps, or synergy. Inattentive or less skilled dance partners may not pick
up on each other's cues or may misread the cues altogether, resulting in uncoordinated
movements and missteps. In a sample clinical incident (see box) that occurred in
a general medical-surgical intensive care unit, the nurse altered her usual way
of relating and allowed the patient's family to take the lead. The nurse's
changing her dance style, so to speak, facilitated synergy between the patient's
wife and the nurse.
Commentary And Application Of The Synergy Model
The sample clinical incident illustrates mismatched dance
styles or conflicting ways of relating between the nurse and the patient's wife.
Because the wife was perceived as controlling, the nurse responded by finding new
ways of interacting with her that would enable both parties to care for the patient.
Although the wife demonstrated love, support, and involvement, these qualities were
displayed primarily in terms of power and control. As such, the nurse's familial
expectations were challenged. By remaining open to learning from and understanding
the wife, however, the nurse was able to find a "happy medium" in this situation
by modulating the nurse's usual way of relating and by altering the customary
activities and interventions for the patient and his family.
By being "ready to face" the wife and "backing
down" when the nurse sensed she was exceeding the wife's limits, the nurse
accommodated the wife's way of coping in the situation. By altering her usual
nursing activities, such as coordinating the patient's bath when the wife was
able to be there, the nurse meaningfully facilitated the wife's involvement
in caring for the patient and helped to prevent further conflict between the nurse
and the patient's family.
The nurse and the patient's wife in this situation never
related to each other smoothly or achieved interactional synchrony. Their ways of
being in and coping with the situation conflicted. Through the nurse's perseverance,
openness, and understanding, however, she and the patient's wife did ultimately
create synergy or find ways of relating to each other that enabled both parties
to optimize their care for the critically ill patient.
In summary, the nurse and the patient's wife developed
synergy through their evolving relationship, which produced greater results than
their combined results would have been if either had worked without the other. Yet,
the dance or the relationship itself is what created the synergy. With the heavy
emphasis on outcomes in the current healthcare environment, it is important to realize
that the process, namely matching patients' needs with nurses' competencies,
is essential to achieving optimal outcomes. The power of the Synergy Model is that
it focuses on both the process and the outcome.
Clinical Incident: A Challenging
Nurse: I once took
care of a patient with chronic obstructive pulmonary disease, pancreatitis, and
end-stage renal disease who died. I became the primary caregiver because nobody
else wanted to be in the room. I did establish a rapport with [his wife], but I
have to say, it was one of the most challenging cases I can remember. I mean, I
still distinctly remember how my back would just curl under because [the patient]
was hard to maintain-hard to keep him in bed, hard to ventilate him-and [his wife
would] come in and start taking his clothes off and rubbing him down. It was a challenge.
I mean, to find a happy medium where she could be satisfied and feel like she could
do these things for him . . . and my being able to manage his care . . . It was
also constantly a challenge to represent things to her so that she would understand
and allow me to take care of him . . . She was very possessive, like she wouldn't
let anybody else give him a bath, things like that ' which was fine, but I mean
you had to understand her personality, [understand] that she was a really strong
woman, and just be ready to face her.
Interviewer: Did you
ever feel threatened?
Nurse: Not for my
safety, but I definitely felt like I really had to back down . . . My point was
I didn't want to challenge her. But I had to do my care with him.
Interviewer: And you
didn't want to challenge her because . . .?
Nurse: Because that
was what she needed. She needed to feel like she had control. And she was so out
of control and losing her husband and she knew that. I mean, we had really good
moments too, where [we'd] sit and talk about her husband, but it was still hard.
It was never easy. It was a challenge to the end.
Members of the certification think tank who developed the
conceptual framework were Martha A.Q. Curley, RN, PhD, CCRN; Mairead Hickey, RN,
PhD; Patricia Hooper-Kyriakidis, RN, PhD; Wanda Johanson, RN, MN; Bonnie Niebuhr,
RN, MS; Sarah Sanford, RN, MN, CNAA; and Gayle R. Whitman, RN, PhD. Subject matter
experts who defined the continua of patients' and nurses' characteristics were Martha
A.Q. Curley, RN, PhD, CCRN; DuAnne Foster-Smith, RN, MN, CCRN; Deborah Gloskey,
RN, MS, CCRN; Janet Fraser Hale, RN, PhD, CCRN, CS, FNP; Teresa Halloran, RN, MSN,
CCRN; Sonya Hardin, RN, PhD, CCRN; Mairead Hickey, RN, PhD; Patricia Hooper-Kyriakidis,
RN, PhD; Vicki Keough, RN, MSN, TNS, TNCC; Patricia Moloney-Harmon, RN, MS, CCRN;
Kathleen Shurpin, RN, PhD, CS, ANP, OCN; and Daphne Stannard, RN, PhD. Members of
the outcomes think tank who articulated patient outcomes were Patricia Benner, RN,
PhD; Melissa Biel, RN, MSN; Martha A.Q. Curley, RN, PhD, CCRN; Wanda Johanson, RN,
MN; Marion Johnson, RN, PhD; Marguerite Kinney, RN, DNSc; Benton Lutz, MDiv, EdS;
Patricia Moloney-Harmon, RN, MS, CCRN; Alvin Tarlov, MD; and Cheri White RN, PhD,
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