The core concept of the reconceptualized model of certified
practice - the AACN Synergy Model for Patient Care - is that the needs or characteristics
of patients and families influence and drive the characteristics or competencies
of nurses. Synergy results when the needs
and characteristics of a patient, clinical unit or system are matched with a nurse's
competencies.
All patients have similar needs and experience these needs
across wide ranges or continuums from health to illness. Logically, the more compromised
patients are, the more severe or complex are their needs. The dimensions of a nurse's
practice are driven by the needs of a patient and family. This requires nurses to
be proficient in the multiple dimensions of the nursing continuums. When nurse competencies
stem from patient needs and the characteristics of the nurse and patient synergize,
optimal patient outcomes can result.
The AACN Synergy Model and Certification Examinations
The AACN Synergy Model for Patient Care was developed to link
clinical practice with patient outcomes. The integration of the Synergy Model into
the AACN Certification Corporation credentialing programs puts an emphasis on the
patient, and says to the world that patients come first. Nurses make a unique contribution
to outcomes, quality of care and containment of costs.
Recognizing the additional components that comprise critical
care nursing, 20% of the CCRN examination is now based on Advocacy/Moral Agency,
Caring Practices, Collaboration, Systems Thinking, Response to Diversity, Clinical
Inquiry and Facilitation of Learning knowledge and skills. These nursing characteristics
are referred to collectively as "Professional Caring and Ethical Practice."
The remaining 80% of the CCRN examination continues to be based on clinical judgment.
Since July 1, 1999, the CCRN examination has included the following
component: Professional Caring and Ethical Practice, which is based on the AACN
Synergy Model for Patient Care. Prior to the application of the Synergy Model framework
to the CCRN certification program, the examination was based solely on clinical
judgment. The Synergy Model, and its incorporation into the CCRN, CCNS and PCCN
exams, is not to have nurses memorize the various patient or nurse characteristics,
or their levels. They are presented here to help you begin to comprehend the model.
Test questions cover application of the Synergy Model, not
its terminology.
Each patient and family, clinical unit and system is unique,
with a varying capacity for health and vulnerability to illness. Each one brings
a set of unique characteristics to the care situation. These characteristics span
the health-illness continuum.
Resiliency--the
capacity to return to a restorative level of functioning using compensatory/coping
mechanisms; the ability to bounce back quickly after an insult.
Level 1 - Minimally resilient
- Unable to mount a response; failure of compensatory/coping mechanisms; minimal
reserves; brittle
Level 3 - Moderately resilient
- Able to mount a moderate response; able to initiate some degree of compensation;
moderate reserves
Level 5 - Highly resilient
- Able to mount and maintain a response; intact compensatory/coping mechanisms;
strong reserves; endurance
Vulnerability--susceptibility
to actual or potential stressors that may adversely affect patient outcomes.
Level 1 - Highly vulnerable
- Susceptible; unprotected, fragile
Level 3 - Moderately vulnerable
- Somewhat susceptible; somewhat protected
Level 5 - Minimally vulnerable
- Safe; out of the woods; protected, not fragile
Stability--the ability
to maintain a steady-state equilibrium.
Level 1 - Minimally
stable - Labile;
unstable; unresponsive to therapies; high risk of death
Level 3 - Moderately
stable - Able to maintain steady state for limited period
of time; some responsiveness to therapies
Level 5 - Highly
stable - Constant; responsive to therapies; low risk
of death
Complexity--the
intricate entanglement of two or more systems (e.g., body, family, therapies).
Level 1 - Highly complex
- Intricate; complex patient/family dynamics; ambiguous/vague; atypical presentation
Level 3 - Moderately complex
- Moderately involved patient/family dynamics
Level 5 - Minimally complex
- Straightforward; routine patient/family dynamics; simple/clear cut; typical presentation
Resource availability--extent
of resources (e.g., technical, fiscal, personal, psychological, and social) the
patient/family/community bring to the situation.
Level 1 - Few resources
- Necessary knowledge and skills not available; necessary financial support not
available; minimal personal/psychological supportive resources; few social systems
resources
Level 3 - Moderate resources
- Limited knowledge and skills available; limited financial support available; limited
personal/psychological supportive resources; limited social systems resources
Level 5 - Many resources
- Extensive knowledge and skills available and accessible; financial resources readily
available; strong personal/psychological supportive resources; strong social systems
resources
Participation in care--extent
to which patient/family engages in aspects of care.
Level 1 - No participation
- Patient and family unable or unwilling to participate in care
Level 3 - Moderate level of participation - Patient and family need assistance in care
Level 5 - Full participation
- Patient and family fully able to participate in care
Participation in decision-making--extent to which patient/family engages in decision-making.
Level 1 - No participation
- Patient and family have no capacity for decision-making; requires surrogacy
Level 3 - Moderate level of participation - Patient and family have limited capacity; seeks input/advice
from others in decision-making
Level 5 - Full participation
- Patient and family have capacity, and makes decision for self
Predictability--a
characteristic that allows one to expect a certain course of events or course of
illness.
Level 1 - Not predictable
- Uncertain; uncommon patient population/illness; unusual or unexpected course;
does not follow critical pathway, or no critical pathway developed
Level 3 - Moderately predictable
- Wavering; occasionally-noted patient population/illness
Level 5 - Highly predictable
- Certain; common patient population/illness; usual and expected course; follows
critical pathway
For example:
A healthy, uninsured, 40-year-old woman undergoing a
pre-employment physical is likely to be: (a) stable
(b) not complex (c) very predictable (d) resilient (e) not vulnerable (f) able to
participate in decision-making and care, but (g) has inadequate resource availability.
A critically ill infant with multisystem organ failure is likely to be: (a) unstable (b) highly complex (c) unpredictable
(d) highly resilient (e) vulnerable (f) unable to become involved in decision-making
and care, but (g) has adequate resource availability.
Nursing care reflects an integration of knowledge, skills,
experience, and attitudes needed to meet the needs of patients and families. Thus,
continuums of nurse characteristics are derived from patient needs. The following
are levels of expertise ranging from competent (1) to expert (5):
Clinical Judgment--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 informal experiential knowledge and evidence-based guidelines.
Level 1 - Collects basic-level
data; follows algorithms, decision trees, and protocols with all populations and
is uncomfortable deviating from them; matches formal knowledge with clinical events
to make decisions; questions the limits of one's ability to make clinical decisions
and delegates the decision-making to other clinicians; includes extraneous detail
Level 3 - Collects and
interprets complex patient data; makes clinical judgments based on an immediate
grasp of the whole picture for common or routine patient populations; recognizes
patterns and trends that may predict the direction of illness; recognizes limits
and seeks appropriate help; focuses on key elements of case, while shorting out
extraneous details
Level 5 - Synthesizes
and interprets multiple, sometimes conflicting, sources of data; makes judgment
based on an immediate grasp of the whole picture, unless working with new patient
populations; uses past experiences to anticipate problems; helps patient and family
see the "big picture;" recognizes the limits of clinical judgment and
seeks multi-disciplinary collaboration and consultation with comfort; recognizes
and responds to the dynamic situation
Advocacy and Moral Agency--working
on another's behalf and representing the concerns of the patient/family and nursing
staff; serving as a moral agent in identifying and helping to resolve ethical and
clinical concerns within and outside the clinical setting.
Level 1 - Works on behalf
of patient; self assesses personal values; aware of ethical conflicts/issues that
may surface in clinical setting; makes ethical/moral decisions based on rules; represents
patient when patient cannot represent self; aware of patients' rights
Level 3 - Works on behalf
of patient and family; considers patient values and incorporates in care, even when
differing from personal values; supports colleagues in ethical and clinical issues;
moral decision-making can deviate from rules; demonstrates give and take with patient's
family, allowing them to speak/represent themselves when possible; aware of patient
and family rights
Level 5 - Works on behalf
of patient, family, and community; advocates from patient/family perspective, whether
similar to or different from personal values; advocates ethical conflict and issues
from patient/ amily perspective; suspends rules - patient and family drive moral
decision-making; empowers the patient and family to speak for/represent themselves;
achieves mutuality within patient/professional relationships
Caring Practices--nursing
activities that create a compassionate, supportive, and therapeutic environment
for patients and staff, with the aim of promoting comfort and healing and preventing
unnecessary suffering. Includes, but is not limited to, vigilance, engagement, and
responsiveness of caregivers, including family and healthcare personnel.
Level 1 - Focuses on
the usual and customary needs of the patient; no anticipation of future needs; bases
care on standards and protocols; maintains a safe physical environment; acknowledges
death as a potential outcome
Level 3 - Responds to
subtle patient and family changes; engages with the patient as a unique patient
in a compassionate manner; recognizes and tailors caring practices to the individuality
of patient and family; domesticates the patient's and family's environment; recognizes
that death may be an acceptable outcome
Level 5 - Has astute
awareness and anticipates patient and family changes and needs; fully engaged with
and sensing how to stand alongside the patient, family, and community; caring practices
follow the patient and family lead; anticipates hazards and avoids them, and promotes
safety throughout patient's and family's transitions along the healthcare continuum;
orchestrates the process that ensures patient's/family's comfort and concerns surrounding
issues of death and dying are met
Collaboration--working
with others (e.g., patients, families, healthcare providers) in a way that promotes/encourages
each person's contributions toward achieving optimal/realistic patient/family goals.
Involves intra- and inter-disciplinary work with colleagues and community.
Level 1 - Willing to
be taught, coached and/or mentored; participates in team meetings and discussions
regarding patient care and/or practice issues; open to various team members' contributions
Level 3 - Seeks opportunities
to be taught, coached, and/or mentored; elicits others' advice and perspectives;
initiates and participates in team meetings and discussions regarding patient care
and/or practice issues; recognizes and suggests various team members' participation
Level 5 - Seeks opportunities
to teach, coach, and mentor and to be taught, coached and mentored; facilitates
active involvement and complementary contributions of others in team meetings and
discussions regarding patient care and/or practice issues; involves/recruits diverse
resources when appropriate to optimize patient outcomes
Systems Thinking--body
of knowledge and tools that allow the nurse to manage whatever environmental and
system resources exist for the patient/family and staff, within or across healthcare
and non-healthcare systems.
Level 1 - Uses a limited
array of strategies; limited outlook - sees the pieces or components; does not recognize
negotiation as an alternative; sees patient and family within the isolated environment
of the unit; sees self as key resource
Level 3 - Develops strategies
based on needs and strengths of patient/family; able to make connections within
components; sees opportunity to negotiate but may not have strategies; developing
a view of the patient/family transition process; recognizes how to obtain resources
beyond self
Level 5 - Develops, integrates,
and applies a variety of strategies that are driven by the needs and strengths of
the patient/family; global or holistic outlook - sees the whole rather than the
pieces; knows when and how to negotiate and navigate through the system on behalf
of patients and families; anticipates needs of patients and families as they move
through the healthcare system; utilizes untapped and alternative resources as necessary
Response to Diversity--the
sensitivity to recognize, appreciate and incorporate differences into the provision
of care. Differences may include, but are not limited to, cultural differences,
spiritual beliefs, gender, race, ethnicity, lifestyle, socioeconomic status, age,
and values.
Level 1 - Assesses cultural
diversity; provides care based on own belief system; learns the culture of the healthcare
environment
Level 3 -Inquires about
cultural differences and considers their impact on care; accommodates personal and
professional differences in the plan of care; helps patient/family understand the
culture of the healthcare system
Level 5 - Responds to,
anticipates, and integrates cultural differences into patient/family care; appreciates
and incorporates differences, including alternative therapies, into care; tailors
healthcare culture, to the extent possible, to meet the diverse needs and strengths
of the patient/family
Facilitation of Learning--the
ability to facilitate learning for patients/families, nursing staff, other members
of the healthcare team, and community. Includes both formal and informal facilitation
of learning.
Level 1 - Follows planned
educational programs; sees patient/family education as a separate task from delivery
of care; provides data without seeking to assess patient's readiness or understanding;
has limited knowledge of the totality of the educational needs; focuses on a nurse's
perspective; sees the patient as a passive recipient
Level 3 - Adapts planned
educational programs; begins to recognize and integrate different ways of teaching
into delivery of care; incorporates patient's understanding into practice; sees
the overlapping of educational plans from different healthcare providers' perspectives;
begins to see the patient as having input into goals; begins to see individualism
Level 5 - Creatively
modifies or develops patient/family education programs; integrates patient/family
education throughout delivery of care; evaluates patient's understanding by observing
behavior changes related to learning; is able to collaborate and incorporate all
healthcare providers' and educational plans into the patient/family educational
program; sets patient-driven goals for education; sees patient/family as having
choices and consequences that are negotiated in relation to education
Clinical Inquiry (Innovator/Evaluator)--the ongoing process of questioning and evaluating practice and
providing informed practice. Creating practice changes through research utilization
and experiential learning.
Level 1 - Follows standards
and guidelines; implements clinical changes and research-based practices developed
by others; recognizes the need for further learning to improve patient care; recognizes
obvious changing patient situation (e.g., deterioration, crisis); needs and seeks
help to identify patient problem
Level 3 - Questions appropriateness
of policies and guidelines; questions current practice; seeks advice, resources,
or information to improve patient care; begins to compare and contrast possible
alternatives
Level 5 - Improves, deviates
from, or individualizes standards and guidelines for particular patient situations
or populations; questions and/or evaluates current practice based on patients' responses,
review of the literature, research and education/learning; acquires knowledge and
skills needed to address questions arising in practice and improve patient care;
(The domains of clinical judgment and clinical inquiry converge at the expert level;
they cannot be separated)
For example:
If the gestalt of a patient were stable but unpredictable,
minimally resilient, and vulnerable, primary competencies of the nurse would be
centered on clinical judgment and caring practices, (which includes vigilance).
If the gestalt of a patient were vulnerable, unable to participate
in decision-making and care, and inadequate resource availability, the primary competencies
of the nurse would focus on advocacy and moral agency, collaboration, and systems
thinking.
All eight competencies are essential for contemporary nursing
practice, but each assumes more or less importance depending on a patient's characteristics.
Synergy results when the needs and characteristics
of a patient, clinical unit or system are matched with a nurse's competencies.
These characteristics must be viewed in context. Various assumptions
regarding nurses, patients and families guide the Synergy Model:
- Patients are biological, psychological, social, and spiritual
entities who present at a particular developmental stage. The whole patient (body,
mind and spirit) must be considered.
- The patient, family and community all contribute to providing
a context for the nurse-patient relationship.
- Patients can be described by a number of characteristics.
All characteristics are connected and contribute to each other. Characteristics
cannot be looked at in isolation.
- Similarly, nurses can be described on a number of dimensions.
The interrelated dimensions paint a profile of the nurse.
- A goal of nursing is to restore a patient to an optimal
level of wellness as defined by the patient. Death can be an acceptable outcome,
in which the goal of nursing care is to move a patient toward a peaceful death.