Nursing Theory

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M AGNET® STATUS IS AWARDED by the American Nurses’ Credentialing Center (ANCC) to hospitals that

satisfy a set of criteria designed to measure the strength and quality of their professional nursing prac- tice. Designation as a Magnet hos- pital originated in the 1980s. It was awarded to hospitals that were successful in recruiting and retain- ing nurses during the nursing shortage of that time (Gleason, Sochalski, & Aikin, 1999). It is pur- ported that nurses in Magnet-des- ignated hospitals deliver excellent patient outcomes (The Center for Nursing Advocacy, 2006). When a health care organization receives Magnet designation, it is recogni- tion of a facility’s attainment of excellence (ANCC, 2006a).

“The Magnet Recognition Pro- gram® identifies and defines the ‘Forces of Magnetism’ as the char- acteristics displayed by health care organizations that develop and maintain a professional practice environment that helps recruit and retain nurses” (ANCC, 2004). To

date, over 200 hospitals in the United States and one in Australia are recognized with Magnet desig- nation (ANCC, 2006b). For a health care organization to receive Magnet designation, the environ- ment must be provided where nursing care promotes attainment of the highest achievable patient outcomes (ANCC, 2004). Evalu- ation of patient outcomes is an important topic because of the concern about the quality of healthcare.

One of the 14 Forces of Magnetism requires a health care organization to have a professional model of care. The eligibility requirements stipulate that this model must be utilized throughout the health care system and that the same philosophy must be used throughout the system. The model of care is to “give nurses the responsibility and authority for the provision of direct care.” Further, “the models of care provide for the continuity of care across the con- tinuum.” The models take into consideration patients’ unique

EXECUTIVE SUMMARY One of the 14 Forces of Mag- netism requires a health care organization to have a profes- sional model of care. The eligibility requirements stip- ulate that this model must be utilized throughout the health care system and that the same philosophy must be used throughout the system. The American Association of Critical-Care Nurses Synergy Model for Patient Care de- scribes nursing practice based on eight patient characteristics, and also describes eight nurse competencies. The core concept of the model is that the needs or characteris- tics of patients and families influence and drive the charac- teristics 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. The synergy model is an excel- lent framework to organize the work of patient care throughout the health care system. It can be used and applied in various ways and provides a comprehensive framework for assuring success in building a philosophy that supports the Forces of Magnetism.

Roberta Kaplow Kevin D. Reed

The AACN Synergy Model for Patient Care: A Nursing

Model as a Force of Magnetism

ROBERTA KAPLOW, PhD, RN, AOCNS, CCNS, CCRN, is a Clinical Nurse Educator, Innovex, Inc., Parsippany, NJ. She is an immediate past member of the AACN Board of Directors and former Director of the AACN Certification Corporation. She is also co-editor of Synergy for Clinical Excellence. The AACN Synergy Model for Patient Care and Critical Care Nursing. Synergy for Optimal Outcomes.

KEVIN D. REED, MSN, RN, CNA, BC, is the Director of Adult Critical Care Services/ Neurosciences, Clarian Health Partners, Indianapolis, IN, which uses the AACN Synergy Model for Patient Care as the model for nursing practice. He is also the Chair of the AACN Certification Corpora- tion.

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needs and provide skilled nurses and adequate resources to accom- plish desired outcomes” (ANCC, 2005).

Related Practice Models While use of a nursing model

to guide care has the potential to affect patient outcomes, use has been the subject of criticism. The primary source of this criticism has been on their value and pur- pose in nursing practice. Their importance in nursing science has also been doubted (Tierney, 1998; Wimpenny, 2002).

Despite the questionable value of nursing models, data from other multidisciplinary research has supported a relationship between use of models and attainment of patient outcomes, including mor- tality and patient satisfaction (Gleason et al., 1999). The data, however, are variable in their results.

Earley and colleagues (2006) compared outcomes of patients who underwent an appendectomy using an acute care surgery model with those using a traditional home-call attending surgeon model. In this study, patients with acute appen- dicitis who were cared for by an in-house acute care surgeon had significantly decreased the time to operation, rupture rate, complica- tion rate, and hospital length of stay as compared with the tradi- tional home-call attending surgeon model.

Parley (2001) studied persons with learning disabilities. Data from this study suggest that out- comes are improved when a per- son-centered care model was used. When this model was used, staff were being more respectful to clients and there were improved opportunities for clients to make everyday choices. The researcher concluded that in order for this model to be effective, a multidisci- plinary approach to care is essen- tial.

Siminerio, Zgibor, and Solano (2004) described use of a chronic care model to improve diabetes

care processes and outcomes in clinical settings. Aspects of the model included decision support, clinical information systems, self- management education, and deliv- ery system design. Improved pa- tient outcomes were reported with use of this model.

Mark, Salyer, and Wan (2003) evaluated the impact of profes- sional nursing practice on organi- zational and patient outcomes. Their results suggest a positive relationship between professional nursing practice and nursing satis- faction but only partial effect on other organizational or patient out- comes. Patient outcomes in this study included patient satisfac- tion; collaboration among physi- cians, nurses, and other staff; and satisfaction with pain relief and level of comfort sharing concerns with nurses. Organizational out- comes included nurses’ work satis- faction, nursing turnover, and length of patient stay. In this study, professional nursing practice was defined as “a system that supports registered nurse control over the delivery of nursing care and the environment in which care is delivered” (p. 224).

Results from other studies sug- gest a relationship between profes- sional nursing practice and im- proved patient outcomes. A signifi- cant inverse relationship has been reported between professional nurs- ing practice and mortality rates (Aiken, Smith, & Lake, 1994; Aiken, Sloan, Lake, Sochalski, & Weber, 1999). Other researchers revealed a significant inverse relationship be- tween professional nursing practice and needlestick injuries (Aiken, Sloan, & Klocinski, 1997). Units with professional nursing practice reportedly have safer work environ- ments (Institute of Medicine, 1983).

Burnes-Bolton and colleagues (1990) reported an increase in patient satisfaction on a medical/ surgical unit using the cost con- tainment model of Cedars-Sinai Medical Center. The authors attrib- uted the increased patient satisfac- tion scores based on the percep-

tion that nurses were spending more time with patients and fami- lies. Similar findings were report- ed by Lamb and Huggins (1990), who reported increased patient satisfaction and decreased length of stay in two diagnostic groups. The model used in this latter study was the St. Mary’s Professional Nursing Network.

Daly, Rudy, and Thompson (1991) evaluated outcomes of chronically critically ill patients. They reported increased patient and family satisfaction in patients in a special care unit for chronical- ly critically ill patients as com- pared with patients in a traditional intensive care unit.

While some positive relation- ships between nursing models and patient outcomes have been reported, these studies are dated and a number of methodologic issues have been reported on these same studies. These issues relate to how and why the outcomes were selected for each of the stud- ies, sampling issues, lack of ran- domization, lack of a theoretical link between the nursing model and patient outcomes selected, and timing of the studies (Weisman, 2006).

The AACN Synergy Model for Patient Care

In the 1990s, the American Association of Critical-Care Nurses (AACN) assembled a think tank to discuss an envisioned new para- digm for nursing practice and cre- ate a conceptual framework for certified practice. The think tank members agreed that certified practice should be based on meet- ing patient needs and optimizing outcomes rather than delineating a set of skills performed by nurses caring for acute and critically ill patients (Hardin, 2005).

From the original work of the think tank came a description of characteristics a patient brings to a health care setting and a set of competencies that a nurse brings to the bedside. Those original lists were later modified by a group of

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Table 1. Characteristics of Patients, Clinical Units, and

Systems of Concern to Nurses

subject matter experts to the eight patient characteristics and eight nurse competencies of the AACN Synergy Model of Patient Care (Hardin, 2005).

The AACN Synergy Model for Patient Care describes nursing practice based on the eight patient characteristics. These characteris- tics span the health-illness contin- uum (AACN, 2006). The patient characteristics are resiliency, vul- nerability, stability, complexity, resource availability, participation in care, participation in decision making, and predictability.

The synergy model also de- scribes eight nurse competencies. These competencies consist of clinical judgment, advocacy and moral agency, caring practices, col- laboration, systems thinking, response to diversity, facilitation of learning, and clinical inquiry. According to the synergy model, “nursing care reflects an integra- tion of knowledge, skills, experi- ence, and attitudes needed to meet the needs of patients and families. Thus, continuums are derived from patient needs” (AACN, 2006). The continuum ranges from 1 to 5, where 1 = competent; 5 = expert (AACN, 2006). Each of the patient characteristics and nurse competencies are described in Tables 1 and 2, respectively.

The core concept of the model 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 charac- teristics of a patient, clinical unit, or system are matched with a nurse’s competencies (AACN, 2006).

The underlying tenets of the synergy model are: (a) patients’ characteristics are of concern to nurses; (b) nurses’ competencies are important to patients; (c) pa- tients’ characteristics drive nurses’ competencies; and (d) when pa- tients’ characteristics and nurses’ competencies match and syner- gize, outcomes for the patient are optimal (Hardin & Kaplow, 2005).

The assumptions guiding the

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; fail- ure of compensatory/cop- ing 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 compensa- tory/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; some- what 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 limit- ed 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; sim- ple/clear cut; typical presenta- tion.

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 finan- cial support not available; minimal personal/psycho- logical supportive resources; few social sys- tems resources.

Level 3 Moderate resources. Limited knowledge and skills available; limited financial support avail- able; limited personal/psycho- logical supportive resources; limited social systems resources.

Level 5 Many resources. Extensive knowledge and skills available and accessible; financial resources readily available; strong personal/ psychologi- cal 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 unwill- ing to participate in care.

Level 3 Moderate level of participa- tion. Patient and family need assistance in care.

Level 5 Full participation. Patient and family fully able to participate in care.

Table continues on next page

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Table 2. Nurse Competencies of Concern to Patients,

Clinical Units, and Systems

CLINICAL JUDGMENT: Clinical reasoning, which includes clinical decision making, critical think- ing, 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; fol- lows algorithms, decision trees, and protocols with all populations and is uncom- fortable deviating from them; matches formal knowledge with clinical events to make decisions; questions the lim- its of one’s ability to make clinical decisions and dele- gates the decision making to other clinicians; includes extraneous detail.

Level 3 Collects and interprets com- plex patient data; makes clini- cal judgments based on an immediate grasp of the whole picture for common or rou- tine patient populations; rec- ognizes 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 conflict- ing, sources of data; makes judgment based on an imme- diate grasp of the whole pic- ture, unless working with new patient populations; uses past experiences to anticipate problems; helps patient and family see the “big picture;” recognizes the limits of clini- cal judgment and seeks mul- tidisciplinary collaboration and consultation with com- fort; recognizes and responds to the dynamic situation.

Table 1. (continued) Characteristics of Patients, Clinical Units, and

Systems of Concern to Nurses

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 participa- tion. 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 path- way.

SOURCE: American Association of Critical Care Nurses Certification Corporation. http://www.aacn.org/DesktopModules/Certifications/pages/Certifications/general/synmodel.aspx #Patient

AACN Synergy Model for Patient Care are: • Patients are biological, psycho-

logical, social, and spiritual entities who present at a partic- ular developmental stage. The whole patient (body, mind, and spirit) must be consid- ered.

• The patient, family, and com- munity all contribute to pro- viding 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 de- scribed on a number of dimen- sions. The interrelated dimen- sions 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 peace- ful death (AACN, 2006). Since its inception in the

1990s, the synergy model has been used in a variety of clinical and academic settings. Reed, Cline, and Kerfoot (2007) from Clarian Health Partners, Indianapolis, IN, which has Magnet designation, describe how the synergy model has been implemented in their facilities. Other facilities nation- wide are in various phases of implementing the model. Pope (2002) suggests considering imple- menting the synergy model to opti- mize patient outcomes. Several clinical anecdotes and case studies of how the synergy model was implemented and optimized pa- tient outcomes in the clinical prac- tice setting are available on the AACN Web site at www.certcorp. org/certcorp/certcorp.nsf/edcfc72 ba47aaa708825666b0064bdcf/53b a8a716a70373d882567f700046eb4 ?OpenDocument.

Table continues on next page

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The Synergy Model as a Professional Model of Care

Conceptual models are impor- tant because they illuminate what is essential or relevant to a disci- pline (Curley, 2004). The evidence that has been presented supports the idea that models for profes- sional nursing practice lead to improved patient outcomes. When utilized as a professional model of care, the synergy model provides a framework that defines the nurse’s relationship with the patient, other nurses, and the health care system. The model can also facilitate the evolution of a common language for nurses in identifying and com- municating the needs of patients. It provides a viable means for delineating the role of professional nurses in directly impacting the outcomes of patients and ultimate- ly the overall success of health care organizations (Reed et al., 2007).

The synergy model is an excel- lent framework to organize the work of patient care throughout the health care system (Kerfoot, 2004). It can be used and applied in various ways and provides a comprehensive framework for assuring success in building a phi- losophy that supports the Forces of Magnetism. The three components of the model (patient characteris- tics, nurse competencies, and the health care environment) are all integral parts that interact hyper- dynamically to form a professional model of practice.

The patient side of the model provides a means of describing patients and their families in a way that resonates with nurses and other caregivers. It provides the opportunity to build a common language for caregivers as they de- scribe patient needs. More impor- tantly, it emphasizes patient cen- trality and the need to know the patient. Further, the patient side of the model facilitates the develop- ment of nursing practice that is grounded in the nurse-to-patient relationship.

Table 2. (continued) Nurse Competencies of Concern to Patients,

Clinical Units, and Systems

Table continues on next page

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 val- ues; aware of ethical con- flicts/issues that may sur- face in clinical setting; makes ethical/moral deci- sions based on rules; rep- resents 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; sup- ports 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/repre- sent themselves when possi- ble; aware of patient and fam- ily rights.

Level 5 Works on behalf of patient, family, and community; advo- cates from patient/family per- spective, whether similar to or different from personal val- ues; advocates ethical conflict and issues from patient/family perspective; suspends rules; patient and family drive moral decision making; empowers the patient and family to speak for/represent them- selves; achieves mutuality within patient/professional relationships.

CARING PRACTICES: Nursing activities that create a compassionate, supportive, and therapeu- tic environment for patients and staff, with the aim of promoting comfort and healing and pre- venting unnecessary suffering. Includes, but is not limited to, vigilance, engagement, and responsiveness of caregivers, including family and health care 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 out- come.

Level 3 Responds to subtle patient and family changes; engages with the patient as a unique patient in a compassionate manner; recognizes and tai- lors caring practices to the individuality of patient and family; domesticates the patient’s and family’s environ- ment; recognizes that death may be an acceptable out- come.

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 communi- ty; caring practices follow the patient and family lead; antici- pates hazards and avoids them, and promotes safety throughout patient’s and fami- ly’s transitions along the health care continuum; orchestrates the process that ensures patient’s/family’s comfort and concerns sur- rounding issues of death and dying are met.

Utilizing the eight characteris- tics of patients embedded in the AACN Synergy Model, patient needs can be identified along a continuum of illness utilizing the assessment parameters of vulnera- bility, resiliency, stability, com- plexity, predictability, resource availability, participation in deci- sion making, and participation in

care (Reed et al., 2007). As out- lined in the eligibility require- ments for Magnet designation, the model provides a means for identi- fying and discussing patients’ needs in an organized and struc- tured way, addressing their uniqueness and providing for care continuity throughout the episode of illness. The characteristics out-

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lined by the patient side of the model can then be utilized to develop nurse communication via nurse-to-nurse report, documenta- tion systems, and the articulation of patient acuity. The information collected by assessing the patients’ needs assists in the development of an individualized plan of care and helps to identify the nurse competencies required to meet those needs.

The nurse characteristics out- lined by the synergy model pro- vide a comprehensive and contem- porary view of the work of nurses (Curley, 1998). The eight compe- tencies included in the nurse side of the model, including clinical judgment, caring practices, advo- cacy/moral agency, response to diversity, clinical inquiry, facilita- tor of learning, collaboration, and systems thinking provide a frame- work to articulate the work of nurses and enables the ability to differentiate various levels of expertise. They can serve as a basis for nurse job descriptions that dis- tinguish various levels of nursing practice for the purpose of skill enhancement, professional devel- opment, and career advancement.

The nurse side of the model delineating the eight characteristics of nurses can be utilized to differ- entiate practice and assure that the competencies of the nurse match the needs of the patient. It can serve as a trajectory for career development, including leadership skills, that spans the continuum from novice to expert practitioner. The environment side of the model addresses the context in which patient needs and nurse competen- cies come together. Without an environment that supports these two sides of the model, the synergy will be less than optimal and the realization of the best outcomes will not occur.

The development of job de- scriptions based on the nurse char- acteristics of the synergy model serves as a blueprint for defining nursing practice and competencies that link to the needs of patients

Table 2. (continued) Nurse Competencies of Concern to Patients,

Clinical Units, and Systems

Table continues on next page

COLLABORATION: Working with others (e.g., patients, families, health care 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 meet- ings 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 men- tored; elicits others’ advice and perspectives; initiates and par- ticipates 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 men- tored; facilitates active involve- ment and complementary con- tributions 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 health care and non-health care systems.

Level 1 Uses a limited array of strategies; limited outlook – sees the pieces or com- ponents; does not recog- nize negotiation as an alter- native; 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 compo- nents; 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 out- look – sees the whole rather than the pieces; knows when and how to negotiate and navi- gate through the system on behalf of patients and families; anticipates needs of patients and families as they move through the health care system; utilizes untapped and alterna- tive 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 health care environment.

Level 3 Inquires about cultural differ- ences and considers their impact on care; accommo- dates personal and profession- al differences in the plan of care; helps patient/family understand the culture of the health care system.

Level 5 Responds to, anticipates, and integrates cultural differences into patient/family care; appre- ciates and incorporates differ- ences, including alternative therapies, into care; tailors health care culture, to the extent possible, to meet the diverse needs and strengths of the patient/family.

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and their families (Hardin & Kaplow, 2005). Each of the eight nurse characteristics of the model allows for the categorization of essential elements of nursing prac- tice that span the continuum of novice to expert. Performance standards designed to enhance patient, nurse, and system out- comes can then be leveled to form the framework for a career advancement program. Movement along the career advancement con- tinuum includes progressive de- grees of autonomy and authority that evolve through formal and experiential learning. Defined as the expectation of independent nursing judgment, autonomy has been reported by Magnet hospital staff nurses as an essential compo- nent of Magnetism and is one of the 14 Forces outlined by ANCC for Magnet hospitals (Kramer & Schmalenberg, 2004).

Differentiated practice and the support of professional develop- ment require ongoing competency- based educational programming characterized by judgment, intel- lect, leadership, and contribution (Paccini, 2005). Creating this type of programming to support the use of the synergy model promotes higher levels of independent nurs- ing judgment where autonomy and accountability are enhanced. Cur- ricula designed to enhance the competencies outlined by the nurse characteristics of the model can also support movement toward Magnet status by demon- strating support and value for per- sonal and professional growth and development.

The context of the health care environment provides the back- drop for the synergy model and determines the successful interac- tion between the nurse and patient characteristics. This side of the model includes the gestalt of orga- nizational values that support, rec- ognize, reward and, value the con- tribution of nurses. These qualities are inherent in the core values of the Magnet Recognition Program and include shared decision mak-

ing, competitive salaries, adequate resources, professional develop- ment opportunities, and positive interdisciplinary relationships. It includes the organizational ele- ments of excellence in nursing care that is referred to as the Forces of Magnetism.

When all three sides of the

synergy model are in place, it can provide the framework for a pro- fessional model of care that sup- ports excellence in nursing care and satisfies the criteria outlined in the Magnet designation pro- gram. When fully developed, it optimizes the ability to opera- tionalize all of the Forces of

Table 2. (continued) Nurse Competencies of Concern to Patients,

Clinical Units, and Systems

FACILITATION OF LEARNING: The ability to facilitate learning for patients/families, nursing staff, other members of the health care team, and community. Includes both formal and infor- mal facilitation of learning.

Level 1 Follows planned education- al programs; sees patient/family education as a separate task from deliv- ery 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 per- spective; 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 under- standing into practice; sees the overlapping of educational plans from different health care providers’ perspectives; begins to see the patient as having input into goals; begins to see individualism.

Level 5 Creatively modifies or devel- ops patient/family education programs; integrates patient/family education throughout delivery of care; evaluates patient’s understand- ing by observing behavior changes related to learning; is able to collaborate and incor- porate all health care providers’ and educational plans into the patient/family educational program; sets patient-driven goals for educa- tion; sees patient/family as having choices and conse- quences that are negotiated in relation to education.

CLINICAL INQUIRY: The ongoing process of questioning and evaluating practice and provid- ing 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; rec- ognizes the need for fur- ther learning to improve patient care; recognizes obvious changing patient situation (e.g., deteriora- tion, crisis); needs and seeks help to identify patient problem.

Level 3 Questions appropriateness of policies and guidelines; ques- tions current practice; seeks advice, resources, or informa- tion to improve patient care; begins to compare and con- trast 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.)

SOURCE: American Association of Critical Care Nurses Certification Corporation. http://www.aacn.org/DesktopModules/Certifications/pages/Certifications/general/synmodel. aspx#Nurse

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Magnetism. It provides a common philosophy to clearly set the direction for what is often referred to as the “Magnet jour- ney” by defining the work of patient care, the profes- sional development of nurses, and ultimately continuous improvement of patient, nurse, and sys- tem outcomes.

The synergy model is congru- ent with the Nursing Care Report Card for Acute Care Settings frame- work for outcome analysis (Curley, 1998). When evaluating the use of the model as a basis for nursing care delivery, three levels of out- comes can be delineated; those derived from the patient, the nurse, and the health care system. Out- comes, including nurse-sensitive indicators that help to distinguish nursing’s unique contribution to patients and their families, can be considered for measurement. These include such things as patient satisfaction, complication rates, failure to rescue, and cost. Although clear and distinct link- ages between the use of the model and outcomes are difficult to infer, several anecdotal reports illustrat- ing the results of the use of the syn- ergy model appear in the literature.

The model has been used in an array of clinical settings. Descrip- tive reports and case studies exem- plify how the model guided clini- cal care of acute and critically ill patients (Hardin & Hussey, 2003; Smith, 2006), and helped to attain optimal patient outcomes (Annis, 2002; Ecklund & Stamps, 2002; Hartigan, 2000; Hayes, 2000; Markey, 2001; Rohde & Moloney- Harmon, 2001). Additionally, the model has served as a framework for conducting nursing rounds (Mullen, 2002) and in use with interdisciplinary planning (Annis, 2002; Small & Moynihan, 1999).

The synergy model has also been implemented by educators both in the academic setting as the conceptual framework for clinical nurse specialist curricula (Cox &

Galante, 2003; Zungolo, 2004) and in the clinical arena (Kaplow, 2002).

Reports further exemplify how the synergy model has been used by advanced practice nurses to pro- mote optimal patient outcomes. The model provides a framework to assist APNs to identify levels of patient characteristics and match the needs of the patient and family with the competencies of the nurse providing care (Collopy, 1999; Moloney-Harmon, 1999).

Nurse leaders have utilized the synergy model in a number of ways. These include helping de- termine adequate staffing ratios (Hartigan, 2000), as a framework for nurse job descriptions, peer review evaluations, and develop- ing a clinical advancement pro- gram. The developers of this latter program reported using outcomes measurements, including financial indicators, as components of the program (Czerwinski, Blastic, & Rice, 1999). Other outcomes re- ported to be achieved through the development of a clinical ad- vancement program using the model include improvement in Leapfrog quality and safety meas- ures, patient satisfaction, nursing turnover, and the use of contracted labor (Cox, Reed, & Cline, 2007).$

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