THE SYNERGY MODEL FOR PATIENT CARE OF THE AMERCIAN ASSOCIATION OF CRITICAL CARE NURSES

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CHAPTER 2 CONCEPTUAL FRAMEWORK: THE SYNERGY MODEL FOR PATIENT CARE OF THE AMERICAN ASSOCIATION OF CRITICAL CARE NURSES

INTRODUCTION

A conceptual model is a set of highly abstract but related constructs that reveal the connections between all the most prominent elements and assumptions of a model in such a way that the philosophical foundations of the model are clearly revealed (Burns & Grove 2005:128). According to Polit and Beck (2006:115), a conceptual framework or conceptual model represents a less formal method of organising phenomena than a theory.
In nursing science, conceptual models enable one to decrease extraneous variations among nurses and to decrease the number of plausible interventions that are available as they strive to improve patient outcomes. Conceptual models that guide nursing practice function to keep the nurses in an organisation focused on the paths that are indicated in their mission statement about care giving (Kerfoot, Lavandero, Cox, Triola, Pacini & Hanson 2006:21). Such conceptual frameworks or models tend to reinforce safe, highquality care, treatment and services. Consistency in nursing practice can only be developed and maintained when orientation, continuing education, performance evaluation, specialty certification, career advancement and future planning are all directly related to the provisions of the mission statement and the work that must be performed before successful patient outcomes can be achieved (Kerfoot 2005:335).
Demarrais and Lapan (2003:55), Finlay and Gough (2003:470), and Munhall and Chenail (2007:8) agree that a conceptual framework serves the following purposes in research:
• It enables the most important concepts to be integrated in a logical manner.
• It provides a schematic description of relationships among independent, dependent, moderator, control and extraneous variables.
• It identifies and sets out the assumptions that underlie the study.
• It demonstrates the links that exist between research results and research objectives.
2.1.1 The American Association of Critical Care Nurse Certification Synergy Model for Patient Care
The researcher decided to use the AACN Synergy Model for Patient Care to guide this study because the patient is always the focal point and centre of nursing practice and because this particular model is applicable to all patients in all settings. This particular model also indicates the links between practice and outcomes. The AACN (2003) points out that the core concept of the AACN Synergy Model for Patient Care is the way in which the needs and characteristics of patients and their families influence and determine the competencies that nurses require if they are to perform their jobs efficiently and effectively (Kaplow & Reed 2008:25). Another advantage of the AACN Synergy Model for Patient Care for this research is that it is readily adaptable to the acute and critical care setting where patients are critically ill and where the competencies and skills of nurses need to be practised in the context of their patients’ personal characteristics and idiosyncrasy (Hardin & Hussey 2003:73).

HISTORICAL BACKGROUND

The AACN Synergy Model for Patient Care has become widely accepted as a viable model for professional nursing practice in the 21st century (Reed, Cline & Kerfoot 2007:3).
According to Curley (1998:64) the AACN specifically undertook to design a model that would describe nursing practice in terms of the needs and characteristics of patients and the demands of the health care environment that will become universally prevalent in this 21st century. When a perfect match emerges from interactions that occur when characteristics of patients who come into contact with the professional competencies and abilities of nurses, a creative and energetic synergy emerges that maximises desirable patient outcomes. Optimal outcomes are evaluated on the basis of those that are derived from the patient, the nurse and the health care system. This model is therefore known as the “Synergy Model” (Curley 1998:64).
Although the AACN Synergy Model for Patient Care is used as a basis for the certification of acute and critical care nurses, this model can also help to situate the nursing profession within the current health care environment – especially as it relates to CPR (Curley 1998:65).

THE AACN SYNERGY MODEL FOR PATIENT CARE

The term synergy may be defined as a mutually advantageous conjunction or compatibility of completely separate agents, participants or elements (such as resources or efforts) (Merriam Webster’s Online Medical Dictionary 2007). Synergy is an evolving phenomenon that occurs when individuals or groups work together to incorporate the benefits of innovative, grounded and holistic thinking towards the realisation of a common goal (Curley 1998:64).
The AACN Synergy Model for Patient Care was specifically developed to provide a rational method for linking practice to patient outcomes. It therefore reflects how nursing care that integrates knowledge, skills, experiences and attitudes are able to meet the needs of patients and their families (Ecklund & Stamps 2002:60). The AACN Synergy Model for Patient Care enables a researcher or administrator to clearly identify the unique needs of patients and to describe how these can be met by particular competencies, qualities, skills and abilities in environments in which nurses have to practice. It stands to reason that an absence of synergy between the needs of a patient and the abilities of a nurse will result in unsafe and unsatisfactory standards of care. An absence of synergy therefore also implies that health care professionals such as nurses can no longer ensure that optimal standards of care in nursing in a variety of situations in which patients find themselves. The AACN Synergy Model for Patient Care can also be extended to describe the various aspects of nurse-patient, nurse-nurse and nurse-system relationships that constitute the contemporary health care environment (Curley 2004:64). The AACN Synergy Model for Patient Care describes three kinds of outcomes: (1) those derived from the patient, (2) those derived from the nurse, and (3) those derived from the health care system (see Figure 2.1). These three outcomes are discussed in detail in the following chapters.

The major tenets of the AACN Synergy Model for Patient Care

In what follows, the AACN Synergy Model for Patient Care will be discussed in detail. Since the AACN Synergy Model for Patient Care establishes the patient as the centre and focus of all health care efforts, it describes how the needs of patients and the skills and abilities of nurses need to interact in order to optimise the outcomes of patient care (Curley 1998:66). The three components of the model (namely, patient characteristics, nurse competencies and the health care system) are all indispensable for a comprehensive model of professional practice (Kaplow & Reed 2008:21).These three components are discussed in detail in the following sections: 2.3.3, 2.3.5 and 2.3.7. The AACN Synergy Model for Patient Care offers a framework for evaluating the outcomes for the patient, the nurse and the system (figure 2.1). The AACN Synergy Model for Patient Care also describes eight patient characteristics and eight nurse competencies that together create the environment in which all professional nursing takes place. This process is depicted in figure 2.2 and listed in table 2.1. The actual conditions that prevail in the health care environment provide the inputs that enable the AACN Synergy Model for Patient Care to determine whether or not the interactions between the competencies of the nurse and the characteristics of the patient will be successful or not (Kaplow & Reed 2008:23).
The basic premise of the model is that the needs of the patients and their families drive and determine the characteristics and competencies of nurses. Synergy occurs when the needs and characteristics of a patient, a clinical unit or a system are matched by a nurse’s competencies (Curley 1998:66). The model is therefore relevant to all kinds of practice settings.
2.3.2 Assumptions that guide the AACN Synergy Model for Patient Care
The AACN Synergy Model for Patient Care is based on nine different assumptions. The first five were identified in 2000 (AACN 2000), and the last four were added by the AACN Certification Corporation four years later (Muenzen, Greenburg & Pirrol 2004). Most of these assumptions relate to the patient and the nurse, although the hospital system can be addressed both directly and indirectly by the same assumptions (Alspach 2006:11). The AACN Synergy Model for Patient Care is constructed on the foundations of the following nine assumptions (each of these assumptions is expressed in terms of a declaration or assertions):
• 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.
• The nurse creates the environment for the care of the patient. The environment of care also affects what the nurse can do.
• There is interrelatedness between impact areas, which may change as the experience, situation, and setting change.
• The nurse may work to optimise outcomes of patients, families, healthcare providers, and the healthcare system.
• The nurse brings his or her background to each situation, including various levels of education/knowledge and skills/experience.
The goal of nursing is always to restore a patient to an optimal level of wellness in good health as defined by the patient. There are eight nursing competencies that contribute towards the complete picture of the professional nursing. These eight competencies are:
• clinical judgement
• advocacy/moral agency
• caring practices • collaboration
• systems thinking
• responses to diversity
• facilitation of learning
• clinical inquiry. While these characteristics are discussed in some detail in section 2.3.5, patient characteristics will not be discussed in much detail in this study because this study confines itself to an investigation of the characteristics of the nurse and the health care system. It was stated above that the goal of nursing is to restore a patient to an optimal level of wellness as defined by the patient himself/herself. Because of this qualification, death may well be an acceptable outcome to a patient. Although a nurse creates the environment in which the care of the patient will take place, the environment thus created will either impede or enable what a nurse is able to accomplish (AACN 2003:4). The different aspects of the environment that a nurse creates are all related to one another through the agency of the nurse as a facilitator of care. The way in which the elements of the environment change may be regarded as a function of the experience of the caregivers, the condition of the patients and the setting itself (Muenzen et al 2004). The nurse therefore enjoys the unique advantage in being able to optimise outcomes for patients, families, health care providers and the health care system or organisation itself. All nurses bring the totality of their life skills, knowledge, wisdom, experience, understanding and moral qualities to every professional situation in which they are involved (Curley 1998:64).
The author (Curley 1998:64) is of the opinion that these assumptions constitute the foundations on which the framework of the AACN Synergy Model for Patient Care may be understood and developed. The AACN Synergy Model for Patient Care is a conceptual framework for designing practice and for developing the competencies that are required for units in personnel that specialise in the care of critically ill patients (Hardin & Kaplow 2005:9).
The patient characteristics, the nurse competencies and the resultant outcomes from the interactions that occur between the patient, the nurse and the system are listed in table 2.1. Among the many characteristics that are present, 8 are consistently seen in patients who experience critical events. These 8 characteristics are consistently assessed by nurses in variable levels given each patient situation (Hardin & Kaplow 2005:8).
From table 2.1 it can be seen that each patient brings a set of unique characteristics to the healthcare situation. These characteristics, as well as other patterns that are unique to each patient’s circumstances, should be assessed in every patient. These characteristics are discussed in section 2.3.3.
The nurse characteristics can be considered competencies that are essential for those providing care to the critically ill. All eight competencies may reflect an integration of knowledge, skills and experience of the nurse. Outcomes derived from the patient include functional changes, behavioural changes, trust, satisfaction, comfort and quality of life. Outcomes derived from nursing competencies include physiological changes, the presence or absence of complications and the extent treatment objectives were obtained (Curley 1998:65). These are discussed in detail in section 2.3.5.
Outcome data derived from the healthcare system include recidivism, cost utilisation per case. These are discussed in detail in section 2.3.7.
2.3.3 Patient characteristics as described in the AACN Synergy Model for Patient Care
The AACN Synergy Model for Patient Care explains how each patient brings a unique cluster of personal characteristics to any health care situation. The AACN Synergy Model for Patient Care also enables us to understand how patient characteristics can refer to the vulnerabilities and personal difficulties with which patients may present during the course of their illness or their contacts with health care personnel. In order to broaden her understanding of the model, the researcher has incorporated the insights contained in Curley (1998:64), Kaplow and Hardin (2007:5), Hardin and Kaplow (2005:7) and Kerfoot et al (2006:23). Each patient and family are unique and every family and individual manifest different degrees of health and fitness and different vulnerabilities to illness and dysfunction. An individual’s capacity for health is mediated by his/her genetic inheritance and biological conformations, and is also influenced by a variety of different factors such as exercise, stress reduction techniques, the institutions of the community in which the individual resides, and the community perceptions and social organisations that surround an individual (Curley 1998:64).
All these elements influence the kind of nursing care that is required by a particular patient and the patient’s family. The AACN Synergy Model for Patient Care describes how nursing practice is based on eight patient characteristics that cover the whole health-illness continuum (AACN 2006).
The eight patient characteristics defined by the AACN Synergy Model for Patient Care are (2.3.3.1) resiliency, (2.3.3.2) vulnerability, (2.3.3.3) stability, (2.3.3.4) complexity, (2.3.3.5) resource availability, (2.3.3.6) participation in care, (2.3.3.7) participation in decision making and (2.3.3.8) predictability. In the sections that follow, these patient characteristics are described and discussed.
These characteristics vary in terms of the level of need manifested by each patient. The patients characteristics is assessed using a 5 point Likert scale, ranging from 1 (the worst patient state) to 5 (the best patient state). These levels range from worse through moderate to best on a scale of 1-3-5 (see tables 2.2.1 till 2.2.8). Level 1 means that the patient’s characteristic is not adequate enough to assist in the provision of healthcare; level 3 means that the characteristic is moderately adequate to assist; and level 5 indicates total adequacy of that character in the patient.
2.3.3.1 Resiliency
Resiliency has been defined (Felten & Hall 2001:50) as the ability to achieve, retain or regain a level of physical or emotional health after the impact of a devastating illness, disappointment or loss. The definition of resiliency supplied by the AACN Synergy Model for Patient Care read that “the patient’s capacity to return to a restorative level of functioning by using compensatory and coping mechanisms; the ability to bounce back quickly after an insult” (Curley 1998:65).The person with low level resiliency may have less compensatory mechanism whereas a person with high resiliency may have strong coping mechanism and able to maintain the equilibrium. During cardiac arrest, the level of resiliency or coping capability is influenced by the co-morbid conditions like hypertension, diabetes and by various kinds of health behaviours like diet, exercise, stress, alcoholism and smoking. Higher resilience in the patient’s characteristic assists in the provision of healthcare.
2.3.3.2 Vulnerability
Vulnerability is defined (Malone 2000:1) as “the susceptibility to particular harmful agents, conditions, or events at particular times”. Vulnerability is considered to be something that needs to be avoided and resisted The definition of vulnerability provided by the AACN Synergy Model for Patient Care is “the susceptibility to actual or potential stressors that may adversely affect patient outcomes” (Curley 1998:65).

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Table of contents
CHAPTER 1 INTRODUCTION AND OVERVIEW OF THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND TO THE RESEARCH PROBLEM
1.3 STATEMENT OF THE RESEARCH PROBLEM
1.4 SIGNIFICANCE OF THE RESEARCH
1.5 PURPOSE OF THE RESEARCH
1.6 RESEARCH OBJECTIVES
1.7 PHASES OF THE RESEARCH
1.8 RESEARCH QUESTIONS
1.9 DEFINITIONS OF KEY TERMS
1.10 CONCEPTUAL FRAMEWORK
1.11 ASSUMPTIONS
1.12 THE RESEARCH DESIGN AND METHODOLOGY
1.13 ETHICAL CONSIDERATIONS
1.14 DIVISION OF CHAPTERS
1.15 CONCLUSION
CHAPTER 2 CONCEPTUAL FRAMEWORK: THE SYNERGY MODEL FOR PATIENT CARE OF THE AMERCIAN ASSOCIATION OF CRITICAL CARE NURSES
2.1 INTRODUCTION
2.2 HISTORICAL BACKGROUND
2.3 THE AACN SYNERGY MODEL FOR PATIENT CARE
2.4 APPLICATION OF THE AACN SYNERGY MODEL FOR PATIENT CARE DURING DURING CARDIO-PULMONARY RESUSCITATION
2.5 APPLICATION OF THE AACN SYNERGY MODEL FOR PATIENT CARE IN   VARIOUS SETTINGS
2.6 CONCLUSION
CHAPTER 3 LITERATURE REVIEW
3.1 INTRODUCTION
3.2 CONCEPTUAL FRAMEWORK
3.3 BRIEF HISTORICAL REVIEW ON CARDIO-PULMONARY RESUSCITATION (CPR)
3.4 HAEMODYNAMICS OF, AND PATIENT CHARACTERISTICS DURING CARDIAC ARREST AND CARDIO-PULMONARY RESUSCITATION (CPR)
3.5 AED ALGORITHM
3.6 DRUGS ADMINISTERED DURING ACLS
3.7 ALGORITHMS
3.8 PROVISION OF EDUCATIONAL TOOLS BY THE HEALTHCARE SYSTEMS –   MANIKINS
3.9 MILESTONES ON THE WAY TO DEVELOPMENT OF INTERNATIONAL GUIDELINES 2000 – THE FIRST INTERNATIONAL CONFERENCE ON GUIDELINES FOR CPR AND ECC
3.10 FACTORS THAT PRECIPITATED MAJOR CHANGES IN THE 2005 AHA   GUIDELINES FOR CPR AND ECC
3.11 ETHICAL PRINCIPLES OBSERVED FURING CARDIO-PULMONARY RESUSCITATION
3.12 THE OUTCOMES OF CPR
3.13 SCOPE OF PRACTICE FOR NURSES ON BLS, ACLS
3.14 THE CHARACTERISTICS OF CPR AND THE ROLE OF NURSES IN THE   PROVISION OF CPR
3.15 THE ROLE OF INTERNATIONAL COMMITTEES
3.16 FACTORS THAT INFLUENCE THE PERFORMANCE OF CPR
3.17 LITERATURE ON NURSES’ PERCEPTIONS, BARRIERS AND NEEDS IN   PROVIDING CPR
3.18 ROLE OF HEALTHCARE SYSTEM IN THE PERFORMANCE OF CPR
3.19 NURSES’ CHARACTERISTICS AS COMPETENCIES
3.20 NURSES’ PERCEPTIONS OF CPR
3.21 BARRIERS THAT HINDER THE EFFICIENT APPLICATION AND PERFOR- MANCE OF CPR
3.22 HUMAN FACTORS THAT AFFECT THE QUALITY OF CPR
3.23 ACQUIRED IMMUNO-DEFICIENCY SYNDROME (AIDS) AND CPR
3.24 METHODOLOGIES USED IN THE LITERATURE REVIEWS
3.25 CONCLUSION
CHAPTER 4 RESEARCH METHODOLOGY
4.1 INTRODUCTION
4.2 AIM AND PURPOSE OF THE RESEARCH
4.3 PHASES OF THE RESEARCH
4.4 RESEARCH QUESTIONS
4.5 RESEARCH SETTING (THE SYSTEM)
4.6 RESEARCH METHODOLOGY
4.7 RESEARCH METHOD
4.8 PHASE 1: QUANTITATIVE RESEARCH DESIGN
4.9 PHASE 2: QUANTITATIVE RESEARCH DESIGN (NURSE)
4.10 RELIABILITY AND VALIDITY IN QUANTITATIVE RESEARCH
4.11 PHASE 3: QUALITATIVE RESEARCH DESIGN: FOCUS GROUP DISCUS- SIONS WITH REGISTERED NURSES (SYSTEM, NURSE AND PATIENT)
4.12 PHASE 3: QUALITATIVE RESEARCH DESIGN (SYSTEM, NURSE AND   PATIENT) interview schedule for phase 4
4.13 ESTABLISHMENT OF RIGOUR IN QUALITTATIVE RESEARCH
4.14 ETHICAL CONSIDERATIONS
4.15 CONCLUSION
CHAPTER 5 DATA ANALYSIS AND DISCUSSION: THE AUDIT PHASE
5.1 INTRODUCTION
5.2 RESEARCH OBJECTIVES
5.3 DATA ANALYSIS
5.4 AUDITING OF IN-PATIENT DEATH RECORDS
5.5 AUDITING OF THE PROCEDURE MANUAL
5.6 AUDITING OF IN-SERVICE EDUCATION ON CPR IN THE WARDS
5.7 AUDITING OF IN-SERVICE EDUCATION RECORDS IN THE TWO   REFERRAL HOSPITALS
5.8 APPLICATION OF THE FINDINGS OF THE AUDIT PHASE TO THE AACN SYNERGY MODEL FOR PATIENT CARE
5.9 CONCLUSION
CHAPTER 6 DATA ANALYSIS AND DISCUSSION: PHASE 2 EVALUATION OF REGISTERED NURSES’ CPR KNOWLEDGE AND SKILLS
6.1 INTRODUCTION
6.2 DATA ANALYSIS
6.3 DATA ANALYSIS
6.4 PRESENTATION OF THE FINDINGS
6.5 THE SKILLS TEST
6.6 DISCUSSION OF THE FINDINGS
6.7 SUMMARY OF THE DATA ANALYSIS OF THE QUASI-EXPERIMENTAL   RESEARCH CONDUCTED AMONG REGISTERED NURSES IN THE   TWO REFERRAL HOSPITALS
6.8 APPLICATION OF THE FINDINGS OF THE EVALUATION PHASE TO THE   AACN SYNERGY MODEL FOR PATIENT CARE
6.9 CONCLUSION
CHAPTER 7 ANALYSIS AND DISCUSSION OF QUALITATIVE DATA: FOCUS GROUP DISCUSSIONS (A) AND SEMI-STRUCTURED INTERVIEWS (B)
7.A.1 INTRODUCTION
7.A.2 THE PURPOSE OF PHASE 3-A OF THE STUDY
7.A.3 THE PROFILE OF THE PARTICIPANTS
7.A.4 PRESENTATION OF THE QUESTIONS
7.A.5 DATA ANALYSIS FOR PHASE 3-A OF THE STUDY
7.A.6 PRESENTATION OF THEMES, CATEGORIES AND CODING SYSTEM
7.A.7 DISCUSSION OF THE RESULTS OF FOCUS GROUP DISCUSSIONS   (PHASE 3-A)
7.A.8 APPLICATION OF THE FINDINGS OF THE FOCUS GROUP DISCUSSION TO THE AACN SYNERGY MODEL FOR PATIENT CARE
7.A.9 SUMMARY OF THE FINDINGS OF PHASE 3-A
7.B DISCUSSION PHASE – PHASE 3-B
7.B.1 Discussion of data analysis of the semi-structured qualitative interviews   conducted with nurse managers from the two referral hospitals
7.B.2 PURPOSE OF PHASE 3-B OF THE STUDY
7.B.3 DATA ANALYSIS FOR PHASE 3-B OF THE STUDY
7.B.4 DATA STRUCTURE: THEMES AND CATEGORIES
7.B.5 THEME 1: ORGANISATIONAL FACTORS THAT INFLUENCE THE   PERFORMANCE OF REGISTERED NURSES AND NURSE MANAGERS   WHEN THEY PERFORM CPRs
7.B.6 THEME 2: FACTORS LIMITING THE PERFORMANCE OF REGISTERED   NURSES AND NURSE MANAGERS DURING THE PROVISION OF CPR   SERVICES
7.B.7 THEME 3: TRAINING AND DEVELOPMENT NEEDS OF THE REGISTERED   NURSES AND THE NURSE MANAGERS
7.A.8 SUMMARY OF THE FINDINGS OF PHASE 3-B
7.B.9 APPLICATION OF THE FINDINGS OF THE SEMI-STRUCTURED INTERVIEW   TO THE AACN SYNERGY MODEL FOR PATIENT CARE
7.B.10 CONCLUSION
CHAPTER 8 CONCLUSIONS, RECOMMENDATIONS AND LIMITATIONS OF THE STUDY ACCORDING TO THE SYNERGY MODEL FOR PATIENT CARE
8.1 INTRODUCTION
8.2 CONCLUSIONS AND RECOMMENDATIONS FOR AUDIT PHASE   (PHASE 1: SYSTEM)
8.3 CONCLUSIONS AND RECOMMENDATIONS FOR DISCUSSIONS PHASE   (PHASE 3: SYSTEM)
8.4 THEME 1: ORGANISATIONAL FACTORS THAT INFLUENCE THE   PERFORMANCE OF REGISTERED NURSES AND NURSE MANAGERS IN THE PROVISION OF CPR
8.5 THEME 2: FACTORS THAT LIMIT THE PERFORMANCE OF REGISTERED   NURSES AND NURSE MANAGERS DURING THE PROVISION OF CPR   SERVICES
8.6 THEME 3: TRAINING AND DEVELOPMENT NEEDS OF THE REGISTERED   NURSES AND THE NURSE MANAGERS
8.7 CONCLUSIONS AND RECOMMENDATIONS FOR THE EVALUATION PHASE   AND THE DISCUSSION PHASE (THE NURSE)
8.8 CONCLUSIONS AND RECOMMENDATIONS FOR THE DISCUSSION PHASE   (PHASE 3: THE NURSE)
8.9 RECOMMENDATIONS TO IMPROVE LEVELS OF PATIENT CARE BEFORE,   DURING AND AFTER CPR
8.10 LIMITATIONS OF THE RESEARCH
8.11 RECOMMENDATIONS FOR FURTHER RESEARCH
8.12 FINAL CONCLUSIONS
BIBLIOGRAPHY