The Hallmark Health System professional model of care is the Synergy Model – a holistic model where patient/family needs are matched to a nurse’s level of expertise, which directly contributes to optimal patient outcomes. The Synergy Model specifically describes relevant aspects of the nurse-patient, nurse-nurse and nurse-system relationships. The Synergy Model, developed by the American Association of Critical Care Nurses, describes a patient-nurse relationship that supports the primacy of patients and families. All nurse-patient/family assignments are based upon matching patient/family needs to nurse competencies.
Introduction The Synergy Model describes a cluster of personal characteristics that each patient and family brings to a healthcare situation. These 8 characteristics are dynamic and span a continuum of health to illness and include: stability, complexity, vulnerability, predictability, resiliency, participation in decision-making, participation in care, and resource availability. Nursing competencies, derived from the needs of patients, are also described in terms of evolving professional practice. The Synergy Model describes eight dimensions of nursing practice that span the continuum from competent nurse to master clinician nurse. These include clinical judgment, clinical inquiry, caring practices, response to diversity, advocacy/moral agency, facilitation of learning, collaboration and systems thinking. These competencies reflect a dynamic integration of knowledge, skills, experience, and attitudes needed to meet patient’s needs and optimize patient outcomes. The Hallmark Health System professional advancement program is based upon evolving expertise within these eight dimensions of nursing practice.
Within the Synergy Model and consistent with patient/family-centered-care, patients and families are, or assisted to become, active participants in the patient/family-nurse interaction. The interaction is synergistic; specifically, it is reciprocating and co-constituting. The nurse comes to “know” the patient and family and the patient and family comes to “know” the nurse. When this relationship demonstrates engagement and synergistic then optimal patient outcomes are more apt to occur.
- We believe that excellence in care is provided through meaningful therapeutic relationships with patients and their families, continuity in care is a core element of our model of care.
- In support of fostering therapeutic patient/family-nurse relationships, the Clinical Nurse Leaders and Staff Nurses work together to build continuity in nursing care over the patient’s illness trajectory by assigning a limited number of nurses to the patient/family.
- As colleagues, more experienced nurses mentor less experienced nurses.
- Since the needs of patients vary across the system, we have a varying number of Staff Nurses and Advanced Practice Nurses who provide varying levels of expertise on each unit to best accommodate patient needs.
Assumptions: Each patient and family is unique with various capacities for health and vulnerability to illness. Patients possess a singular genetic and biological makeup that establishes their capacity for health. Each individual practices various degrees of healthy behaviors, for example, healthy diet, exercise, and stress reduction. Each lives in a community with different economic structures, government, social organization and community perceptions. All exist within a macro social structure consisting of societal infrastructure, the physical environment, cultural characteristics, and population perceptions. All these factors place the patient in context of an individual within a unique environment and circumstance that impacts the nursing care required of the particular patient and family.
Patient Characteristics of Concern to Nursing
Stability is the ability to maintain a steady state. Stability can be used to describe any vacillating phenomena that impacts nursing care; for example: physiological stability, psychological stability, emotional stability, family or social stability.
Complexity is defined as the intricate entanglement of two or more systems. This characteristic includes multiple systems and/or therapies, for example, body systems, family and social systems, and/or therapeutic interventions.
Vulnerability is a susceptibility to stressors that may adversely affect patient outcomes. Patient vulnerability considers the patient’s risk for adverse outcomes. For example, individuals may present with co-morbid conditions that place them at high risk for associated adverse outcomes and/or patients receiving certain therapies may be at risk for associated complications. Anticipatory assessment and management of associated risks or co-morbid conditions impacts the patient’s nursing care and recovery.
Predictability is the characteristic that allows one to expect a certain trajectory of illness. While most patients have a predictable course of illness, some individuals do not respond in the typical fashion. When predictable, the patient’s care can be managed using traditional practice guidelines; when unpredictable, practice guidelines are not helpful. Also, when the patient or their diagnosis is unknown, one cannot anticipate the patient’s response to interventions or predict the patient’s trajectory of illness.
Resiliency is the capacity to return to a restorative level of functioning using compensatory and coping mechanisms. Given the patient’s individuality, some patients easily return to a stabile state where others do not. How a nurse approaches and plans interventions that may challenge the patient’s stability is certainly based upon the individual’s capacity to restore homeostasis.
Participation in decision-making describes the extent to which the patient or family engages in decision-making. The patient’s and family’s capacity, desire, and level of decision-making in daily management and overall treatment vary dramatically within the care environment. At different points during their illness, the nurse stands in for, or beside a patient and family to support them though a decision that will impact their care and management.
Participation in care describes the extent to which the patient and family participates in care activities. Again, the patient’s and family’s capacity, desire, and level of participation in care vary dramatically within the care environment. At different points during their illness, the nurse either provides or helps the patient and family give care.
Resource availability is the extent of resources the patient, family, or community brings to the care situation. Resources include personal, physiological, social, technical and financial. The extent of available resource impacts the level of support nurses need to provide patients and their families.
Nurse Competencies of Concern to Patients and Their Families
The Synergy Model nurse dimensions are used to frame nursing competence within Hallmark Health System. The competencies form the basis of the nursing job descriptions. Evolving expertise in each dimension is linked to the Hallmark Health System Department of Nursing Professional Recognition Program. As individual nurses level’s of expertise are determined, an optimal balance of clinician, advanced clinician, expert clinician and master clinicians on a unit is determined based upon the patient population served.
Clinical judgment is the ability of nurses to use their clinical knowledge to affect patient outcome. It is defined as 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. Patricia Benner’s From Novice to Expert has enriched how the Nursing profession has come to understand clinical knowledge development. Clinical wisdom is not solely dependent on years of experience but on experience gained from years of learning and applying knowledge gained to each successive patient.
Clinical inquiry involves resolving clinical problems that occur at the bedside and in the care environment. It is an ongoing process of questioning and evaluating practice and providing informed practice and creating practice changes or innovation through research utilization and experiential learning. It is a matter of asking good questions, delving into the literature to answer those questions, and bringing the best evidence to the bedside. Clinical inquiry is all about seeing, questioning, finding the evidence, and making practice changes.
Caring practices makes our clinical judgment visible. Caring practices include a constellation of nursing activities which 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. Caring practices, such as presence and vigilance, create a safe environment for patients to be sick in. Caring practices, extended to all members of the care team, creates a therapeutic milieu. Caring practices include not only what nurses do but also how they do it. Pain assessment and management are fundamental caring activities. Nurses are engaged during difficult situations, they help the patient and families understand and decide out how best they can get though tough situations. All patients are unique with different values and beliefs that nurses learn so they can know what is important to the patient and their family.
Response to diversity involves the sensitivity to recognize, appreciate, and incorporate differences in the provision of care. Differences may include, but are not limited to: individuality, cultural differences, spiritual beliefs, gender, racial, ethnicity, family configuration lifestyle, socioeconomic status, age, values, alternative medicine involving patients/families and members of the healthcare team. Nurses help families identify, for themselves, what is important to them as individuals and support them though difficult decisions.
Advocacy/moral agency involves working on another’s behalf and representing the concerns of the patient/family/community and serving as a moral agent in identifying and helping to resolve ethical and clinical concerns within the clinical setting. Because of Nursing’s unique relationship with patients and families, nurses often are the voice for patients who cannot speak for themselves. Nurses carry on the moral tradition of nursing and serve as the patient and family’s moral agent; the person in whom things matter, the person who takes a stand and gives voice to patient and family concerns.
Facilitator of learning refers to nurses’ competency in facilitating patient, family and staff learning. This includes supporting a learning environment characterized by safe discourse, mentoring and team development. Teaching and patient and family learning is embedded in care, from our first interaction, where we orient patients and family to the care environment, to our last interaction, where we finalize instructions for home. We also assume major responsibility in coaching and mentoring the next generation of nurses and members of the interdisciplinary team.
Collaboration includes working with others (patient, family, healthcare providers, colleagues, community) in a way that promotes and encourages each person’s contributions. Collaboration involves intradisciplinary and interdisciplinary work with colleagues and ability to negotiate and resolve conflict. The nurse is the one person who knows the care environment and can pull a team of caregivers together in the best interest of the patient and family.
Systems’ thinking includes appreciating the care environment from a perspective that recognizes the inter-relationships that exist within and across healthcare settings. Making complex systems safe for patients is a skill. Whereas competent nurses operative on a micro level (unit and shift focus) and are just beginning to develop system savvy and strategies to facilitate change, expert nurses operate on a macro level (program and episode of illness focus), possess system savvy and easily apply a variety of strategies to facilitate change within complex systems.
American Nurses Association (2003). Nursing’s social policy statement (2nd ed.). Washington, DC.
Expertise in Nursing Practice: Caring, Clinical Judgment and Ethics. Benner, P., Tanner, C., Chesla, C., (1996). Clinical Wisdom and Interventions in Critical Care: A Thinking in Action Approach. Springer Publishing Co.
Benner P. (1984). From novice to expert: excellence and power in clinical nursing practice. Addison-Wesley Publishing Co., Inc.
Curley MAQ. Synergy: From Theory to Practice. Synergy: Continued. Origins of Synergy. Synergy in Publication. In MAQ. Curley (Editor). The State of Synergy. Excellence in Nursing Knowledge 2004; 1(1) www.nursingknowledge.org/enk
Curley, M.A. (1998). Patient-nurse synergy: optimizing patients' outcomes. American Journal of Critical Care, 7(1), 64-72.
Curley, M., & Wallace, J. (1992). Effects of the nursing participation model of care on parental stress in the PICU: a replication. Pediatric Nursing, 7(6), 377-385.
Curley, M. (1988). Effects of the nursing mutual participation model of care on parental stress in the PICU. Heart Lung, 17(6), 682-688.
Hagerty, B., & Patusky, K. (2003). Reconceptualizing the nurse-patient relationship. Journal of Nursing Scholarship, 35 (2). 145-149.
Tanner, C.A., Benner, P., Chesla, C., Gordon, D.R. (1993). The phenomenology of knowing the patient. Image, 25, 273-280.
The Massachusetts Nurse Practice Act: Massachusetts General Laws (M.G.L) chapters 13, 14, 14a, 15, 15d and chapter 112, 74-81c of 244 CMR sections 3.00-9.00
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