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Nursing Practice PerspectivesErin KibbeyFerris State University AbstractThe purpose of this paper is to investigate and define what drives my nursing practice. An analysis of the American Association of Critical-Care Nurses (AACN) Synergy Model for Patient Care was provided, as well as a description of how and why the model is used as a basis for my own nursing practice. Once the Synergy Model was described as the foundation for my nursing practice, the four patterns of nursing knowledge were defined. Lastly, information was presented supporting my belief that nursing practice is unique and different from other health care professionals. Nursing Practice PerspectivesAccording to the American Nurses Association (ANA) (2010) nursing is defined as the “protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (p. 1). However, the way in which nurses value and interpret these functions can be unique to each individual nurse and consequently is what guides their practice. The purpose of this paper is to first explore what guides my own nursing practice. The second purpose of this paper is to define nursing knowledge and acknowledge how these patterns of knowing make nursing a unique and different discipline than other health care professions. Guides to PracticeAfter a semester learning about nursing theories it is easy to see how these models can be used to provide effective, high quality nursing care that I have always strived to achieve in practice. In fact, following further reflection and research I realized there is one particular theory that has been guiding my practice over the last several years. The American Association of Critical-Care Nurses (AACN) Synergy Model for Patient Care is based on five assumptions that clearly align with my beliefs about the metaparadigms of nursing (AACN Certification Corporation, 2002). These assumptions include: 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. (p. 9)This model was designed to describe nursing practice and the development of nurse competencies based on characteristics and needs of patients, as well as demands of the future healthcare environment (Curley, 1998). Furthermore, the model describes eight competencies of nursing practice including: clinical judgment, advocacy and moral agency, caring practices, facilitation of learning, collaboration, systems thinking, diversity of responsiveness, and clinical inquiry (AACN Certification Corporation, 2002). Patient characteristics include: vulnerability, resiliency, stability, complexity, predictability, resource availability, participation in care, and participation in decision making. The various competencies are utilized based on the patient’s needs; synergy results when a patient’s needs are aligned with a nurse’s competencies.Although I believe there are many nursing theories that incorporate some of the essential components of my own nursing practice, I see the AACN’s Synergy Model as integrating all of them. In addition, I have learned that nursing models and theories should be useful in practice, logical and consistent with validated theories, and provide rationale and consequences of nursing actions, leading to predictable patient outcomes (Kenney, 2013). This is how I see the Synergy Model. The Synergy Model’s metaparadigms and its focus on optimal patient outcomes based on evidence-based nursing interventions are inherent principles of my own nursing practice. Moreover, I believe clinical judgment has a vast role in my practice as a cardiac critical care nurse. To this end, clinical judgment is a core component of nursing practice in the Synergy Model, which is grounded in the nursing process (Peterson & Bredow, 2013). Nursing interventions are planned based on the integration of knowledge and critical thinking. As mentioned earlier in the semester, I work on a busy, acuity adaptable, cardiothoracic surgical unit. I enjoy the complex and critical nature of the patients I take care of; I value using critical thinking skills and knowledge of disease and disease processes. However, I can now say that I see the integration of knowledge and critical thinking used by the Synergy Model, as the engine driving my nursing practice on a unit as fast paced and critical as the one I work on. Furthermore, the acuity adaptable unit I work on actually promotes the Synergy Model by adjusting nurse competencies to the critical level of the patient. As opposed to moving patients that become more or less critical to different units, the approach our acuity adjustable unit takes allows the formation of more intimate relationships from primary caregivers across the continuum of care. The Synergy Model was developed to describe nursing care in a high technology, multifaceted and often hectic environment, such as the unit I practice on (Peterson & Bredow, 2013). As a primary critical care nurse utilizing the Synergy Model, I believe it is imperative to achieve a high level of understanding about my patient’s needs and characteristics in order to prioritize, advocate, educate and plan interventions throughout their care, with the ultimate goal of synergizing the patient through the healthcare environment. According to Curley (1998), safe passage for patients and their families within the healthcare environment requires that the nurse “know the patient” (p. 67). Additionally, Curley stated that knowing can create the possibility of advocacy, thereby limiting vulnerability. As an advocate in this model, nurses help patients do what they cannot do for themselves (Peterson & Bredow, 2013). This component of the Synergy Model aligns perfectly with my beliefs. In essence, I see the nurse characteristic of advocacy as striving to make a difference in the life of my patients in the way they desire, whether it is mentally, physically, emotionally, and/or spiritually. According to Peterson and Bredow:The nurse is the one constant in the trajectory of disease that has the ability to detect subtle changes due to the intense length of care over time. The use of the Synergy Model enhances the nurse’s understanding of the contribution that is brought to the patient and the family through the discipline of nursing. (p. 113) Just as the AACN’s model values the development of nurse competencies, I too am always yearning for new experiences and understanding. “All these competencies reflect a dynamic integration of knowledge, skills, experience, and attitudes needed to meet patients’ needs and optimize patients’ outcomes” (Curley, 1998, p. 66). As science and evidence-based practice evolves along with a patient’s needs and characteristics, so must my knowledge. One way I have helped accomplish this in the past is through attendance at the AACN’s National Teaching Institute (NTI). At NTI, I was able to see new technology and equipment first-hand, as well as attend seminars regarding the latest research on various subjects. In addition, I have been studying and preparing to take the national certification exam for critical care nurses, developed by the AACN, the founders of the Synergy Model, to further my competencies as a nurse in this specialty. Both of these examples could also be viewed as a way of furthering my clinical inquiry skills, another essential component of this model. “Clinical inquiry is the ongoing process of questioning and evaluating practice, providing informed practice based on available data, and innovating through research and experiential learning” (Curley, p. 66).As I continue to pursue my master’s degree in nursing education, I believe the Synergy Model can still be used as the foundation for my practice. In fact, Kaplow (2002) wrote an article about applying the Synergy Model to nursing education. She noted that although the model has been centered on direct patient care since its implementation, “the Synergy Model also provides a basis for the multifaceted role of the nurse educator” (p. 77). Furthermore, in an editorial by Alspach (2006) it was stated that:When I view the Synergy Model from a staff development perspective, however, my mind’s eye can quickly reconfigure 2 components of this triad – transforming Nurse to Preceptor and Patient to Preceptee – and then readily appreciate the relevance and elegance of its corollary attribute; that is, that optimal orientation of the preceptee can best be achieved when the preceptee’s characteristics (expressed as needs) are matched by the preceptor’s characteristics (expressed as competencies). Just as the patient and nurse interact within the healthcare system, the same holds true for the preceptee and preceptor, recreating a parallel triad of interacting components that could affect outcomes in the orientation process. (p. 10)The role of the nurse educator encompasses several of the nursing competencies noted in the Synergy Model some of which include: facilitator of learning, collaboration, caring practices, advocacy and moral agency, and clinical judgment. As a facilitator of learning, teaching moments are created throughout the time of care with patients and their families as well as when working with orientees (Peterson & Bredow, 2013). Furthermore, the Synergy Model can be implemented into curriculum design as described by both the Duquesne University School of Nursing and Marymount University, helping nurses move from novice to expert (Peterson & Bredow). Consequently, I believe this model will continue to guide my practice at the bedside educating patients and their families, precepting new employees, and as I begin my career as a nurse educator. Patterns of KnowingNow that I have wholly examined the AACN’s Synergy Model as the framework guiding my nursing practice, it is equally important to address the patterns of nursing knowledge and describe how these patterns make nursing unique compared to other health care professions. According to Carper (2013) there are four patterns of knowing that “may be conceived as necessary for achieving mastery in the discipline, but none of them alone should be considered sufficient” (p. 31). The first pattern of knowing is empirics, or the science of nursing (Carper, 2013). According to the ANA (2010) the nursing process including: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation is based on empirics. Furthermore, “these steps serve as the foundation of clinical decision-making and support evidence-based practice” (ANA, 2010, p. 22). Scientific data is an example of empirical evidence; this pattern of knowing is well established in nursing epistemology and methods (Fawcett, Watson, Neuman, Hinton Walker Fitzpatrick, 2013). Empiricism is inherent in the guidance of policies and practices of the nursing profession and is one of the main components, as noted earlier, guiding my own nursing practice. The second pattern of knowing according to Carper (2013) is esthetics, or the art of nursing. In contrast to empirical knowledge that is publicly verifiable and recognizable, knowledge gained by esthetics is subjective and achieved through perception, which “goes beyond recognition in that it includes an active gathering together of details and scattered particulars into an experienced whole for the purpose of seeing what is there” (Carper, 2013, p. 26). According to Fawcett et al. (2013), “aesthetic knowing also addresses the ‘artful’ performance of manual and technical skills…developed by envisioning possibilities and rehearsing the art and acts of nursing…developing appreciation of aesthetic meanings in practice and inspiration for developing the art of nursing” (p. 314). Furthermore, Carper notes empathy as being an important component in this pattern of knowledge. I believe the art of nursing is achieved when nurses establish therapeutic relationships and are consequently able to carry out important nursing functions including that of an advocate and an educator. I consider the practice of gaining subjective information from the formation of a therapeutic relationship as an important difference between nursing and other health fields. Accordingly the ANA (2010) states, “central to the nursing practice is the art of caring, which is represented in the personal relationship that the nurse enters with the patient” (p. 23). In order to more fully understand a patient it is important to know what is going on with them mentally, emotionally, and spiritually. Nurses identify the needs of their patients though holistic perspectives (ANA, 2010). Through this process, I believe nurses can help break down barriers that could inhibit better future health. “Nursing includes the diagnosis and treatment of human responses to actual or potential health problems. Registered nurses employ practices that are restorative, supportive, and promotive in nature” (ANA, 2010, p. 23). Furthermore, Carper (2013) notes that when nurses are better able to perceive and empathize with their patients they will have more options for implementing care that is both effective and satisfying. The component of personal knowledge is the third pattern of knowing, according to Carper (2013). I perceive this pattern of knowledge as coinciding with Cody’s (2013) idea that values are a strong component of nursing practice. I consider this another reason the discipline is unique compared to other health care professions. Furthermore, I feel this type of knowledge can really only be achieved through the foundation of a therapeutic relationship. According to Carper (2013) the third pattern of knowing composed of personal knowledge “is concerned with the kind of knowing that promotes wholeness and integrity in the personal encounter, the achievement of engagement rather than detachment, and it denies the manipulative, impersonal orientation” (p. 29). Without a therapeutic relationship nurses may not be able to see all aspects of the patient and practice accordingly. Furthermore, the ANA (2010) states, “all nursing practice, regardless of specialty, role, or setting, is fundamentally independent practice. Registered nurses are accountable for nursing judgments made and actions taken in the course of their nursing practice” (p. 24).The fourth and final pattern of knowing is ethics, or the moral component (Carper, 2013). While nursing has the responsibility of promoting health, alleviating pain and suffering, and conserving life, sometimes the ethical rules do not help us in times when difficult decisions are made based on patient’s moral values and choices (Carper, 2013). Evidence for this pattern of knowing in nursing comes from codes of ethics, standards of practice, and philosophies of nursing (Fawcett et al., 2013). Unfortunately, in nursing practice we do not always agree with the choices patients make nor are there always rules about what choices should be carried out. However, nurses are bound by a professional code of ethics. Through the establishment of therapeutic relationships, nurses are able to learn more about how patients perceive their health and consequently act in an ethical manner when caring out their patient’s wishes. In contrast to other health professions:Nursing thus depends on the scientific knowledge of human behavior in health and in illness, the esthetic perception of significant human experiences, a personal understanding of the unique individuality of the self, and the capacity to make choices within concrete situations involving particular moral judgments. (Carper, 2013, p. 31)ConclusionWhile I never knew the value of having nursing theory as the guiding principle of practice, it is now wholly apparent. Over the semester, information was presented incorporating the need and practical use of nursing theory as a framework for effective nursing practice. Through reflection of this new knowledge, I realized the AACN’s Synergy Model is an excellent guide to my own nursing practice. The model fits the critical nature of the patients I take care of and the values I hold close to my heart. Just as I focus on the needs of my patients, the Synergy Model also places the patient at the center of practice. As I persist in my journey to become a nurse educator, I believe the Synergy Model still has its merits and will continue to be the basis for my nursing practice. Equally important are the four patterns of nursing knowledge that I will continue to value and implement in practice, believing these patterns to be unique to the nursing profession. ReferencesAlspach, G. (2006). Extending the synergy model to preceptorship: A preliminary proposal. Critical Care Nurse, 26(2), 10-12. Retrieved from Association of Critical-Care Nurses (AACN) Certification Corporation. (2002). The AACN Synergy Model for patient care. Retrieved November 30, 2012 from Nurses Association (ANA). (2010). Nursing: Scope and standards of practice (2nd Ed.). Washington, D.C.: author.Carper, B. A. (2013). Fundamental patterns of knowing in nursing. In W. K. Cody (Ed.),?Philosophical and theoretical perspectives for advanced nursing practice?(5th ed.). (pp. 23-33). Burlington, MA: Jones & Bartlett Learning.Cody, W. (Ed.). (2013). Philosophical and theoretical perspectives for advanced nursing practice. (5th ed.). (pp. 5-13). Burlington, MA: Jones & Bartlett Learning. Curley, M. A. (1998). Patient-nurse synergy: Optimizing patients' outcomes.?American Journal of Critical Care,?7(1), 64-72. Retrieved from , J., Watson, J., Neuman, B, Hinton Walker, P., & Fitzpatrick, J. J. (2013). On nursing theories and evidence. In W. K. Cody (Ed.),?Philosophical and Theoretical Perspectives for Advanced Nursing Practice.?(pp.311-319). Burlington, MA: Jones & Bartlett Learning.Kaplow, R. (2002). The synergy model in practice: Applying the synergy model to nursing education. Critical Care Nurse, 22(3), p. 77-81. Retrieved from , J., W. (2013). Theory-based advanced nursing practice. In W. K. Cody (Ed.), Philosophical and Theoretical Perspectives for Advanced Nursing Practice.?(pp. 333-352). Burlington, MA: Jones & Bartlett Learning.Peterson, S., & Bredow, T. (2013). Middle range theories: Application to nursing research (3rd ed.). Philadelphia: Lippincott, Williams, & Wilkins. ................
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