Synergy Model for Patient Care and its Clinical Application

Abstract

Many of the outcomes that are evaluated in health care are measured by illness prevention in the population.  The Synergy Model (SM) for Patient Care developed by the American Association of Critical-Care Nurses (AACN) has been used to prevent chronic illness and promote healthy lifestyles.  This analysis will include an overview of the SM, its 16 concepts, outcomes, usages, and weaknesses.  There will be a brief summary of congestive heart failure (CHF), which is then incorporated into how the SM applies to a CHF clinic based case study.  To support the SM and demonstrate its usefulness, this analysis will explore the SM’s patient and nurse characteristics as they relate to the case study.

The Synergy Model for Patient Care and its Clinical Application

According to Moses et al. (2013), since 1900, the lifespan in the United States has lengthened by 62 percent and today, it is estimated at 76 years of age for men and 81 years of age for women.  With people living longer lives, chronic illnesses coupled with the increasing cost of health care has created tension with which 21^st-century medicine is now grappling.  In order to meet the needs of a community, healthcare professionals utilize disease prevention and promotion of healthy lifestyles to create a care delivery system that produces the best patient outcomes.  In 1996, the AACN developed the SM for Patient Care as a new framework for critical care nursing certification (American Association for Critical-Care Nurses, 2016).  When the SM was applied to nursing practice, it moved the nurse beyond a task list and shifted the central idea of the SM to a relationship focus.  Applying the SM to a CHF clinic based case study will explore its framework, linking patient and nurse characteristics, and depict how a patient’s needs may drive nurse competencies required for patient care (American Association for Critical-Care Nurses, 2016).

SM for Patient Care Overview

According to the AACN, the timeline for the SM began in 1996 and over many years of development, the model then shifted to define nursing beyond a set of tasks and instead defined nursing through both patient and nurse characteristics (American Association for Critical-Care Nurses, 2016).  It became clear that the SM was well suited to serve as a conceptual model to guide nursing care across all dimensions of health care.  The central idea of the SM is that the needs of patients and their families drive and continually influence the characteristics of nurse interventions (Montgomery, Sutton, & Pare, 2017).  When nurse characteristics stem from the needs of patients and families, synergy occurs.  When the model is adopted into clinical practice, teamwork is improved, personnel are maximized to enhance patient safety, financial analysis of health care occurs, and optimal patient outcomes are produced (Butts & Rich, 2018).  Conversely, the absence of synergy results in an ineffective health care experience, incomplete patient evaluations and ultimately a system that can no longer be ensured.

16 Concepts of the SM

Within the SM, there are 16 concepts including eight patient characteristics and eight nurse characteristics.  Each one of the 16 concepts is delineated into a one to five numeric scale.  When measuring the level of expertise, the nurse characteristics range from novice (one) to expert (five).  Similarly, the patient characteristics range from the worst patient state (one) to the best patient state (five)(Butts & Rich, 2018).  Although the levels of both nurse and patient characteristics occur on a continuum and may vary with time, it is this numeric scale that gives measurability, such as minimal, moderate, and high, to each of the 16 concepts (S. Swickard, W. Swickard, Reimer, Lindell, & Winkelman, 2014).  While the nurse characteristics include resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision-making, and predictability, their range of novice to expert is dependent on each patient scenario and their individual characteristics.  The patient characteristics included in the SM are clinical judgment, advocacy and moral agency, caring practices, collaboration, systems thinking, response to diversity, and facilitation of learning (S. Swickward et al., 2014).

Outcomes of the SM

The last component of the SM is the outcomes, which are broken down into three levels.  The first set of outcomes is derived from the patient and includes functional changes, behavioral changes, trust, satisfaction, comfort, and quality of life.  The nurse-derived outcomes include physiological changes, complications, and the extent to which treatment objectives were met.  The final set is the health care system-derived outcomes, which include readmission rate, length of stay, and cost utilization per case (Butts & Rich, 2018).  These three levels of outcomes allow the patient to actively participate in their own care and remain at the center of their care continuum (Montgomery et al., 2017).

Practical Usages the SM

While the development of the SM initially focused on critical care nursing certification, it has a broader application.  The architects of the SM acknowledged that the patient characteristics could be applied to a variety of patient and nurse interactions. S. Swickward et al. (2014) identifies the use of the SM in caring for patients with acute coronary syndromes, while Hardin and Hussey’s (2003) CHF based case study demonstrates another example of the flexibility of the SM.  The SM has been incorporated into professional nurse practice, professional nurse advancement, and has served as a foundation for nursing school curricula (American Association for Critical-Care Nurses, 2016).  Additional applications of the SM include, but are not limited to, staff development and building a nursing productivity measure (S. Swickward et al., 2014).

Weakness of the SM

According to Mongtomery et al. (2017), aligning nurse characteristics to patient care needs creates unlimited usage for the SM.  Although the literature strongly supports the adaptation of the SM in a variety of circumstances and for a variety of purposes, Butts and Rich (2018) identify one weakness of the SM.  According to Butts and Rich (2018), when delineating levels of nursing expertise or patient state, the definitions for levels two and four remain undetermined.  This is a concern because without listing all levels of characteristics from beginner (one) to expert (five), both the nurse and patient characteristics will be unknown at those levels.  A SM with defined characteristics at all levels is one that creates a medium to streamline optimal patient care by evaluation and identification of areas that may be deficient.  When synergy occurs, optimal patient-centered care is delivered regardless of the patient’s level of vulnerability (Montgomery et al., 2017).

CHF Case Study

Hardin and Hussey (2003) discussed the application of the SM to a patient experiencing an acute exasperation of their illness at a CHF clinic.  The SM served as the framework for nurses to manage complex patients and to work toward reducing the trajectory of the illness.  The case study identified the life of a patient with CHF as one that is not only functionally limiting, but also severely lowers an individual’s quality of life.  CHF is a progressive and chronic disease that can lead patients to suffer physical limitations and symptoms that prevent them from carrying out ordinary daily activities.  CHF is a major public health problem that currently represents the number one diagnosis of Medicare beneficiaries and costs 10 to 30 million dollars annually (Hardin & Hussey, 2003).  Due to the dramatic incidence and cost associated with CHF, clinics have been formed in the outpatient setting to enhance the appropriate use of therapies, bring about desired health maintenance, and decrease re-hospitalization.  Many of the interventions put into place within these clinics are being executed by advanced practice nurses (APNs) that are relying on the SM to aid in guiding patient counseling, education and follow-ups toward outcome improvement (Hardin & Hussey, 2003).

Patient Assessment

Hardin and Hussey (2003) identified Sophie as an 82-year-old African American woman with CHF who was widowed, lived alone and struggled with finances because her sole income was Social Security.  Although she did have a daughter that cared about her, the daughter was unable to provide any financial support to her mother.  When she presented to the CHF clinic, she was found to be short of breath, had an elevated blood sugar, an elevated blood pressure, an elevated and irregular heart rate, and lower extremity swelling.  In the past 18 months, she was twice re-hospitalized due to a CHF exacerbation leading to comorbidities.

Sophie did not drive and relied on public transportation to travel to the CHF clinic and for her other errands.  In addition to heart disease, she suffered from diabetes mellitus type two, which was diet controlled; also, she took medication to help control her blood sugar.  She did not have insurance other than Medicare, so the out of pocket cost for her monthly medications was $350.  Additionally, one of her recent hospitalizations revealed that she had suffered from a stroke that left her dependent on a cane for ambulation (Hardin & Hussey, 2003).  This not only complicated her returning to the CHF clinic bi-weekly for scheduled follow up appointments, but a recent follow up at the CHF clinic led a APN to a plethora of medical and social findings that needed to be addressed.

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When Sophie presented to the clinic, the APN found out that she had not taken any of her medications for the past three days.  She was reluctant to answer questions because of being fearful for disclosing her personal information to the provider.  It was discovered that due to financials, Sophie had depleted her medications three days before her appointment.  She knew that in three days, the first of the month, she would receive her Social Security check and then be able to get her prescription medications.  She also admitted that due to money she was not eating well and only had three potatoes to eat until the end of the month (Hardin & Hussey, 2003). 

Identifying and Understanding Patient Characteristics

When utilizing the SM as a framework, Sophie’s characteristics are what drive each nursing characteristic in providing her care and optimizing her outcome.  When Sophie arrived to the CHF clinic, her stability was declining.  Her ability to maintain a steady-state equilibrium (Butts & Rich, 2018)was compromised, as she was plagued with disease processes that were worsening faster than she could afford to wait.  Her complexity was increasing as she endured an entanglement of several systems (Butts & Rich, 2018).  Not only was Sophie’s poor nutritional status placing her CHF and diabetes in jeopardy, she was impacted by the lack of financial resources to maintain her medication regimen.  Sophie had limited resource availability with her Social Security representing the sole financial resource of income.  The only mention of a living family member was her daughter, but she could not provide her mother with any supplemental financial support (Hardin & Hussey, 2003).  There is no mention of any available resources within the community in the case study.

 Sophie’s lack of money and resources had increased her vulnerability because her health was put in jeopardy.  She had not told her daughter about the need for money because she knew that her daughter had little financial reserve.  Also, Sophie had lost her husband six years ago and since then, she did not want to take charity from others because she was a proud woman that wanted to continue to be able to take care of herself (Hardin & Hussey, 2003).  These factors contribute to her susceptibility to stressors that may adversely affect her outcomes (S. Swickward et al., 2014).  Although Sophie’s resiliency had been compromised by her lack of money and resources, she was motivated.  She did have good resiliency potential because of her willingness and knowledge to comply with treatment and diet to regain stability.

 Unfortunately, Sophie’s daughter did not have the finances to help support her mother, but she did care about her and was supportive.  Sophie did not suffer from any cognitive impairment, therefore, participation in care and decision-making could be a joint effort between Sophie and her daughter (Hardin & Hussey, 2003).  Given her uncertain predictability in this situation due to an increasing complexity and decreased stability, the APN needed to assist Sophie.  This crisis needed to be resolved quickly, or she would likely need to be readmitted to the hospital.

Identifying and Understanding Nurse Characteristics

Continuing to use the SM as a framework, Sophie’s weight gain, lower extremity swelling, shortness of breath, elevated blood pressure, and elevated heart rate, prompted the APN to use clinical judgment and data analysis in order to make decisions based upon Sophie’s needs.  The APN utilized the knowledge acquired from experience skill-based nursing and evidence-based practice in order to critically think and make appropriate clinical decisions(S. Swickward et al., 2014).  To guide the APN’s clinical judgment, clinical inquiry must be employed in order to gather sufficient assessment findings such as Sophie’s compliance with protocols, thinking, values and beliefs regarding her condition.  Questioning Sophie allowed the APN to discover the innovative strategies that would be most successful to her patient.

In many cases, the patient, their family, and members of various health care disciplines must work toward promoting the needs of the patient in order to deliver optimal outcomes (Butts & Rich, 2018).  This strategy, known as collaboration, allowed the APN to recruit resources for Sophie such as Meals on Wheels to deliver a balanced diet and financial resources to help cover her medication cost at the end of the month (Hardin & Hussey, 2003).  In order to ensure compliance with the interventions being put into place, the APN applied a systems thinking approach to develop proactive strategies that could ensure an improved utilization of environmental and system resources (Butts & Rich, 2018).  The APN explored possible strategies such as follow-up phone calls, clinic sample medications, and indigent programs sponsored by pharmaceutical companies (Hardin & Hussey, 2003).  Seamlessly blended into these strategies is the awareness of the APN in response to diversity.  The APN must have the sensitivity to respect the client’s values and beliefs by incorporating these differences into her provision of care (S. Swickward et al., 2014).  In Sophie’s case, the APN respected her wishes to maintain independence and pride in not accepting charity.  The APN also supported Sophie in her preferences for food choices.

The strategies that the APN developed, integrated and applied, supported Sophie in her decisions to remain independent.  By demonstrating characteristics of both advocacy and moral agency, the APN worked on Sophie’s behalf to empower her to drive moral decision-making (Butts & Rich, 2018).  Whether similar to or different from the APN’s personal values, the APN applied caring practices such as compassion and engagement (Butts & Rich, 2018).  These practices created a supportive environment and allowed the APN to fully engage with and sense how to stand alongside Sophie (Butts & Rich, 2018).  As the APN, facilitation of learning required the integration of patient and family education throughout the delivery of care (Montgomery et al., 2017).  To ensure that Sophie understood her disease process, medications and results of choices in relation to her health, the APN creatively developed methods that evaluated her comprehension by observing behavior changes (Hardin & Hussey, 2003).

Outcomes and Further Evaluation

The APN used the characteristics within the SM to meet the needs of Sophie.  She was connected with Meals on Wheels to deliver her one hot meal per day and she reported that there was enough food to actually save some of it to have with dinner.  The APN made adjustments to Sophie’s medication regimen and made several follow up calls to her home to answer any questions and ensure compliance.  The APN and Sophie agreed on seeking information regarding indigent pharmaceutical programs for several of her medications and to utilize drug sample packs at the end of each month until a program could be found.  Sophie also displayed her resiliency by verbally acknowledging her understanding of the APN’s teaching.  She recognized the importance of performing daily weights and agreed to call the clinic for medication adjustments or fluid restrictions if she experienced weight gains of one pound or greater in 24 hour period of time.

Conclusion

Health care is in a predicament with conflicting expectations among patients, health care providers, and public health and government policy makers.  The health care system must continue to evolve in order to incorporate the understanding of social, personal and cultural dynamics into information technology, health services and information flow (Moses et al., 2013).  There have been many theoretical approaches to nursing care, but as demonstrated in the CHF clinic based case study, the SM illustrates the true value of patient-centered care and the ability to achieve optimal health status for patients (Montgomery et al., 2017).  Using the model as a framework for nurse practice, nursing can have a significant impact on health care by preventing chronic illness, promoting healthy lifestyles, and influencing the delivery, cost, and quality of healthcare to the community (Hardin & Hussey, 2003).

References

• American Association for Critical-Care Nurses. (2016, October 4). AACN Synergy Model for Patient Care. Retrieved from https://www.aacn.org/nursing-excellence/aacn-standards/synergy-model
• Hardin, S., & Hussey, L. (2003). AACN synergy model for patient care case study of a CHF patient. (using the AACN synergy model). Critical Care Nurse, 23(1), 73.
• Montgomery, S. R., Sutton, A. L., & Pare, J. (2017). Rural nursing and synergy.(report). Online Journal of Rural Nursing & Health Care, 17(1), 87. doi:10.14574/ojrnhc.v17i1.431
• Moses, H., Matheson, D. H. M., Dorsey, E. R., George, B. P., Sadoff, D., & Yoshimura, S. (2013). The anatomy of health care in the united states. Jama, 310(18), 1947-1963. doi:10.1001/jama.2013.281425
• Swickard, S., Swickard, W., Reimer, A., Lindell, D., & Winkelman, C. (2014). Adaptation of the AACN synergy model for patient care to critical care transport.(american association of critical-care nurses).Critical Care Nurse, 34(1), 16. doi:10.4037/ccn2014573
  • Textbook citation (Butts)