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Synergy Model PCCN
Which of the following are elements of a healthy work environment: A. BSN as an entry level requirement for all registered nursing staff, achievement of specialty certification within 2 years of practice in an acute or critical care unit, established educational requirements for maintaining licensure as a registered nurse in the organization, required participation on a unit based or organizational based quality improvement committee. B. Skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, authentic leadership. C. Healthy food choices in the cafeteria; non-smoking policies for patients, staff and visitors; provision of exercise programs for staff. D. Certification requirements for nurses working in acute and critical care areas, advanced educational requirements for nurses caring for acutely ill patients, annual peer review as part of the evaluation process. - answer B. The American Association of Critical Care Nurses (AACN) has established a healthy work environment initiative to support and foster excellence in patient care wherever acute and critical care nurses practice. This initiative recognizes that negative, demoralizing and unsafe conditions in the workplace contribute to medical errors, ineffective delivery of care, and conflict and stress among health professionals. In addition, an unhealthy work environment has negative effects on recruitment and retention, and patient outcomes. The 6 elements of a healthy work environment include: Skilled Communication: Nurses must be as proficient in communication skills as they are in clinical skills. True Collaboration: Nurses must be relentless in pursuing and fostering true collaboration. Effective Decision Making: Nurses must be valued and committed partners in making policy, directing and evaluating clinical care and leading organizational operations. Appropriate Staffing: Staffing must ensure the effective match between patient needs and nurse competencies. Meaningful Recognition: Nurses must be recognized and must recognize others for the value each brings to the work of the organization. Authentic Leadership: Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it and engage others in its achievement. Detailed information on the Healthy Work Environment initiative is available at http://www.aacn.org/wd/hwe/docs/hwestandards.pdf You are approached by a staff nurse who is new on the night shift (has been there for 3 months) after successfully completing a critical care course and residency program with a preceptor on day shift. He tells you that he is having problems with two long time night shift coworkers who constantly belittle him, tell him he is not doing things right, and talk about him to other staff behind his back. He is very uncomfortable working with these
two individuals and dreads coming to work when he knows they will be working that night. He tells you that another new nurse on that shift is being treated the same way. You are aware that these two nurses have a reputation for this type of behavior and that other nurses have quit because of it. He asks you if you have any suggestions regarding how to deal with this situation. What would be your best response to him: A.Encourage him and the other new nurse to confront these nurses the next time it happens and tell them they will be reported to human resources if their behavior doesn't change. Suggest that he enlist the rest of the night shift to join them in confronting this destructive behavior. B. Acknowledge his discomfort and encourage him to document and keep a log of specific incidences when they occur. Refer him to literature on workplace bullying and healthy work environments. Encourage him to discuss his concerns with the manager and offer to accompany him if he would be more comfortable doing that with a support person. Ask if he would be interested in joining you in a discussion with the manager and clinical nurse specialist about education for the unit regarding healthy work environments and establishing a healthy workplace initiative on your unit. C. Tell him that this behavior has been going on for years and it is allowed to continue because it is too hard to find night nurses. Tell him he either needs to transfer to another unit or put up with it. D. Tell him you will talk to the manager about this behavior and report these nurses to human resources. Acknowledge that this has happened before but nothing was done about it and he just might have to ride it out until these nurses retire. - answer B. This type of behavior is a form of workplace bullying and occurs often in hospital settings. Disruptive behavior such as this will not go away on its own and should be dealt with as soon as it is identified. Literature on workplace bullying suggests that employees who are being bullied should report the behavior to their supervisor and document specific incidents as they occur. Organizations should have a Code of Conduct and zero tolerance policies regarding workplace bullying and violence in the workplace. Managers and supervisors have a responsibility to enforce those policies and to implement educational programs and initiatives to create a healthy workplace. The American Association of Critical Care Nurses (AACN) has a Healthy Work Environments Initiative that can serve as a resource for developing and maintaining a healthy environment at work. This behavior may eventually have to be reported to Human Resources if it does not stop after appropriate education and intervention from management, but that should not be the first step in dealing with it. Literature on workplace bullying suggests that it is often a result of insecurity and a feeling of being threatened by new situations or people. If that is the case, threats from peers, supervisors, or human resources will not deal with the underlying causes. Staff who are participating in bullying should be given education and an opportunity to improve their performance before being disciplined. Enlisting other staff to confront the behavior as it occurs might be needed in the case of violence, but with disruptive behavior such as what is described here, that would most likely increase conflict and make things worse. The appropriate course of action would be to report the behavior to a supervisor or manager and allow them time to deal with it appropriately.
therapeutically contraindicated.' It is important for nurses to recognize that the patient should determine their primary support person. This primary support person may not be related by blood, but may be considered family to the patient. Unrestricted presence of a support person of the patient's choosing can improve communication, improve patient safety, and enhance staff satisfaction. Nurses should also be engaged in changing unit based practices when there is evidence to support the need for a change. Therapeutic communication skills are required for effective patient education and the facilitation of learning. Which of the following are examples of therapeutic communication: A. The nurse sits across from the patient so she is at the same level as the patient. B. The nurse empathizes with the patient's dilemma. C .The nurse acknowledges the worth of the patient. D. The nurse listens completely before forming any conclusions. E. All of the above. - answer E. There are several components to therapeutic communication including the following: a) empathy, b) unconditional acceptance, c) acknowledging the patient's worth, and d) listening thoroughly before concluding. Non verbal components of therapeutic communication include: a) using a mindful approach, b) communicating at the same level as the patient, and c) avoiding interruptions and distractions. When facilitating learning, which of the following is not an example of a therapeutic communication technique: A. Giving advice. B. Restating. C. Clarifying. D. Focusing. - answer A. The following are examples of therapeutic communication techniques: offering leads, restating, reflecting, focusing, clarifying, sequencing, encouraging participation, encouraging evaluation, making observations, and summarizing. Techniques that are not considered to be therapeutic include: giving advice, using clichés, giving false reassurance, using why questions, asking leading questions, being defensive, and using jargon. When facilitating learning, which of the following is an example of a therapeutic communication technique: A. Asking why questions. B. Using leading questions. C. Giving advice. D. Reflecting. - answer D. The following are examples of therapeutic communication techniques: offering leads, restating, reflecting, focusing, clarifying, sequencing, encouraging participation, encouraging evaluation, making observations, and summarizing.
Techniques that are not considered to be therapeutic include: giving advice, using clichés, giving false reassurance, using why questions, asking leading questions, being defensive, and using jargon. Many patients have a low level of healthcare literacy. This means they have barriers to understanding the complexities of information specific to the world of health care. One strategy that can help improve the outcomes of education in patients with low healthcare literacy is: A. Written materials at the 12th grade level. B. Teach back. C. Formal education classes. D. Hypnosis. - answer B. Low healthcare literacy is not synonymous with low literacy. There are those who can read and write but who do not understand the complex and specific terms and concepts used in the healthcare system. Teach back is a technique where the patient is asked to teach back to the nurse to assure that the nurse has been effective with his or her education. Teach back does not mean the nurse quizzes the patient. Teach back must make the patient feel safe. For example the nurse might say: 'I want to make sure I was clear with my discharge instructions. Will you please share with me when you would call your doctor.' Based on the patient's response the nurse can assess how well the patient understood the instructions. The following would be a barrier to a patient's ability to learn important information necessary for self care: A. Depression regarding a new diagnosis of heart failure. B. A low level of healthcare literacy. C. The patient's IV is beeping during the education session. D. All of the above. - answer D. Conditions for learning include: a) motivation to learn (impacted by depression), b) ability to learn (impacted by low level of healthcare literacy), and c) learning environment (impacted by beeping IV). You have been working on your nursing unit for 3 years. You have observed that several patients who have been readmitted report taking different medications at home at the time of readmission than what you see were listed in their last discharge summary. You are curious as to the reason for this discrepancy and its association with the readmission. This type of curiosity is described as: A. The beginning of potential research. B. Clinical inquiry. C. A component of clinical reasoning. D. All of the above. - answer B. Curiosity regarding clinical observations is an example of clinical inquiry. Clinical inquiry is the foundation for all nursing research. Clinical inquiry is also a component of sound clinical reasoning. You are precepting a nurse who recently transferred to your unit. When explaining to her your unit protocol for central line dressing changes, she shares with you differences in the protocol at the hospital where she previously worked. An appropriate response based on her comment is:
A. Provide written materials on the pathophysiology of essential hypertension so the patient understands why the medications work. B. Consistently using the term high blood pressure instead of hypertension. C. Educating the adult child instead of the patient. D. Quizzing the patient at the end of every educational session. - answer B. Although hypertension is a commonly understood term among health care providers, patients may not understand it to mean the same as high blood pressure. Using consistent terms in plain language can help overcome health literacy barriers. As an advocate and an educator the nurse should look for reasons the patient may not be adherent to treatment recommendations. One reason may be a lack of understanding of the health problem and its consequences as well as the treatment and its benefits. Teach back is another strategy. However, quizzing the patient is threatening and is not the intent of teach back. The intent of teach back to assure that the nurse has been clear. Involving a support person in education is another good strategy, however, this should not exclude the patient. Providing written material on pathophysiology is not an effective strategy in overcoming health literacy barriers. Patients need more information regarding 'how to' engage in self care as opposed to the complexities of understanding the physiological reasons why medicines work. Additionally, the pathophysiology of essential hypertension is not fully understood by even scientists. During the admission assessment your patient (admitted for atrial fibrillation) tells you he no longer wears his CPAP (continuous positive airway pressure) mask because he has not been having any problems sleeping at night. Your most appropriate response in providing information to your patient is: A. I will update your electronic medical record to state that you refuse treatment for your sleep apnea. B. I would like us to talk more about the benefits of your CPAP mask. Your sleep apnea has many health risks. The purpose of the CPAP mask is to reduce those risks. Although you feel you are sleeping well, your untreated sleep apnea may be placing you at risk for several health disorders. I am concerned that your sleep apnea may also be contributing to your atrial fibrillation. C. I am glad that you are sleeping well and no longer need the CPAP. Please make sure you use it again if you start to have a hard time falling asleep at night. D. I think this is something you need to discuss with the doctor who ordered your CPAP. We will need to focus on the atrial fibrillation this admission since that is why you came to the hospital. You can ask your primary care physician at your next visit to discontinue your CPAP since you no longer need it. - answer B. This statement demonstrates an understanding of two important points: 1) The patient may not have a clear understanding of the adverse implications of untreated sleep apnea, and 2) The patient's untreated sleep apnea may be a contributing factor to his atrial fibrillation. Many patients think of obstructive sleep apnea (OSA) only as a nuisance disorder that results in snoring and poor sleep. Instructing patients on the physiological implications of OSA and the associated adverse consequences can assist in gaining buy-in to treatment.
It is important to note that the patient demonstrates a misunderstanding regarding his diagnosis and treatment rather than a refusal of the treatment. Additionally, the nurse needs to take responsibility for patient education and counseling regarding the patient's health issues at every opportunity. As a nurse you are ethically obligated to maintain standards of professional performance. The best definition of standards of professional performance is: A. Maintaining safe clinical practices. B. Adhering to hospital policies and procedures. C. Maintaining competency in technical nursing skills. D. Maintaining a competent level of behavior in the professional role. - answer D. There are two types of professional standards of practice: a) standards of care, and b) standards of professional performance. Adhering to standards of professional performance is accomplished by maintaining a competent level of behavior in the profession role. Adhering to standards of care is accomplished by maintaining a competent level of nursing care. This includes safety in practice, following policies and procedures, and maintaining competency is the skills required in your practice. When making a decision about withdrawing or withholding life saving treatment, the concept of futility is often discussed. The definition of a quantitatively futile medical treatment is: A. The likelihood of an intervention helping a patient is extremely low (i.e. there is a < 1% chance of the treatment being effective). B. An intervention where the cost of the intervention exceeds the expected benefit. C. An intervention that the patient has requested not to have done via his or her advanced directive. D. The intervention will result in low quality benefit. - answer A. Quantitative futility is defined as the likelihood of an intervention helping a patient being extremely low (a < 1% chance of the treatment being effective). Qualitative futility represents the concept that the intervention will result in low quality benefit. Patients have rights to refuse treatments and plan advanced directives regardless of futility. Futility is not related to cost. Components of informed consent include the following: Voluntary decision making without evidence of coercion. A. Provider disclosure of the risk and benefits of the procedure or treatment. B. An understanding of the risks and benefits by the person making the decision. C. Decision making capacity of the patient or surrogate decision maker. D. All of the above. - answer D. All of the following components must be present for informed consent: a) the person giving consent must have the capacity to make decisions, b) the provider must fully disclose risks and benefits, c) the person making the decision must understand the risks, benefits, and options, d) the person must voluntarily consent (there can no coercion), and e) the person must grant permission.
notify the ordering provider of your concerns and receive a modified order for the dose and rate for the potassium replacement. - answer B. There are several ethical principles that govern nursing practice: beneficence, non-maleficence, justice, fidelity, autonomy, veracity, and privacy / confidentiality. Fidelity means you are faithful in doing what you said you would do. Justice is fairness. Autonomy is the patient's right to make his or her own decision, even when this decision is different than what we think is right. Veracity is truthfulness. Privacy and confidentiality are related to protecting the medical information of patients to only those involved in providing care. Beneficence is the obligation to do good and non- maleficence is the obligation to do no harm. Which of the following is the best example of the ethical principle of autonomy: A. You tell a patient's spouse that you will call her with an update on his condition before you leave work at the end of your shift. Although you received a new admission an hour before your shift ended and although their was no change in your other patient's condition, you take the time to call your patient's wife with an update. B. You are concerned about the ordered dose and rate of intravenous potassium. Prior to signing off the order you call the clinical pharmacist to verify your concerns. You then notify the ordering provider of your concerns and receive a modified order for the dose and rate for the potassium replacement. C. You realize you have made an error in allowing a patient to ambulate to the bathroom who has been ordered to maintain strict bedrest until a pseudoaneurysm of the left groin has been ruled out. After returning the patient to bed, and assessing the groin for any change in the wound site, you document the facts about the patient's ambulation and condition of the groin site both pre and post ambulation. D. After your patient has discussed his treatment options with several consulting physicians, he chooses not to have the surgical procedure that has been recommended. Your husband had the same surgery and did well. You respect your patient's choice not to have the surgery although you personally think he should have chosen differently. - answer D. There are several ethical principles that govern nursing practice: beneficence, non-maleficence, justice, fidelity, autonomy, veracity, and privacy / confidentiality. Fidelity means you are faithful in doing what you said you would do. Justice is fairness. Autonomy is the patient's right to make his or her own decision, even when this decision is different than what we think is right. Veracity is truthfulness. Privacy and confidentiality are related to protecting the medical information of patients to only those involved in providing care. Beneficence is the obligation to do good and non- maleficence is the obligation to do no harm. Which of the following is the best example of the ethical principle of fidelity: A. You realize you have made an error in allowing a patient to ambulate to the bathroom who has been ordered to maintain strict bedrest until a pseudoaneurysm of the left groin has been ruled out. After returning the patient to bed, and assessing the groin for any change in the wound site, you document the facts about the patient's ambulation and condition of the groin site both pre and post ambulation.
B. You tell a patient's spouse that you will call her with an update on his condition before you leave work at the end of your shift. Although you received a new admission an hour before your shift ended and although there was no change in your other patient's condition, you take the time to call your patient's wife with an update. C. You are concerned about the ordered dose and rate of intravenous potassium. Prior to signing off the order you call the clinical pharmacist to verify your concerns. You then notify the ordering provider of your concerns and receive a modified order for the dose and rate for the potassium replacement. D. After your patient has discussed his treatment options with several consulting physicians, he chooses not to have the surgical procedure that has been recommended. Your husband had the same surgery and did well. You respect your patient's choice not to have the surgery although you personally think he should have chosen differently. - answer B. There are several ethical principles that govern nursing practice: beneficence, non-maleficence, justice, fidelity, autonomy, veracity, and privacy / confidentiality. Fidelity means you are faithful in doing what you said you would do. Justice is fairness. Autonomy is the patient's right to make his or her own decision, even when this decision is different than what we think is right. Veracity is truthfulness. Privacy and confidentiality are related to protecting the medical information of patients to only those involved in providing care. Beneficence is the obligation to do good and non-maleficence is the obligation to do no harm. Hospice Care includes all of the following EXCEPT: A. Symptom management. B. Pain control. C. Curative treatments. D. Medical supplies. - answer C. Palliative care is specialized medical care for people with serious illness. Palliative care is focused on providing relief from the symptoms, pain, and stress of serious illness and providing quality of life for both the patient and the family. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment. Hospice care is a type of palliative care provided by a team of professionals and volunteers who provide medical psychological, emotional, and spiritual support to terminally ill patients and their families. These patients usually have less than a year to live. Hospice focuses on pain relief and symptom control while covering medications, medical supplies and treatments. Hospice serves dying patients and efforts to cure or prolong life are no longer pursued in Hospice care. Within the context of the synergy model, synergy occurs when: A. The needs of the nurse are met by organizational policies and procedures. B. The needs of the patient are matched to the competencies of the nurse. C. Two nurses combine efforts to provide improved care to a patient. D. Patients partner with their families and communities to improve their health. - answer B. The core of the Synergy Model for patient care is that the characteristics of patients and families determine the needed competencies of the nurse. Synergy results when the needs of the patient matched to the competencies of the nurse.
You are caring for a 88 year old male patient who is admitted with acute decompensated heart failure. The patient is in pulmonary edema and has evidence of hypoperfusion. For your shift his CAM-ICU is positive for delirium and his urine output is 220 ml for past 8 hours. He has a history of chronic obstructive pulmonary disease, coronary artery disease, aortic stenosis, chronic kidney disease stage IV, and depression. He lives alone and his children live out of state. There have been no vistors since his admission two days ago. What best describes this patient's characteristics according to the Synergy Model: A. Highly vulnerable, highly complex, minimally stable, limited resources, impaired participation in care and decision making. B. Moderately predictable, moderately complex, moderate level of participation, moderately resilient. C. Highly complex, highly stable, highly predictable, high level of resources. D. Minimally vulnerable, highly resilient, highly predictable, full participation in decision making. - answer A. This patient is very vulnerable given his age, diagnosis, and comorbid conditions. His decompensated state, multiple comorbidities and lack of family support make him complex. He is in pulmonary edema and is hypoperfusing his end organs (he has delirium and poor renal function). These factors make him miminally stable. While in delirium he is limited in his participation and decision making. He lives alone with children who live out of state. There have been no visitors since admission. These factors support his limited resources. You are caring for a patient who is a Jehovah Witness. She had an interventional cardiology proicedure and developed a large hematoma after her arterial sheath was pulled. She received over one liter of fluid in response to associated hypotension. Hemostasis has been achieved and the patient is stable. A hemoglobin and hematocrit were checked and her hemoglobin dropped from 11.1 g/dL to 8.9 g/dL. From a remote computer, the residentl on call places an electronic order to transfuse 2 units of packed red blood cells. To demonstrate the competencies of response to diversity and advocacy the nurse does the following: A. Refuse to carry out the order and file a variance report before you leave. B. Call the resident to discuss options other than transfusion of blood products for this patient. C. Explain to the patient that the benefits of the transfusion are more important than her religious beliefs and it is just not realistic to honor her beliefs under these cirumstances. D. Give the transfusion to the patient after she is asleep so she can receive the needed treatment without it causing her emtional distress. - answer B. The most appropriate answer is to call the ordering resident and discuss treatment options. As the nurse you are obligated to advocate for your patient. Knowing your patient's religious beliefs do not allow for the acceptance of blood products, it is your duty to communicate the patient's religious belief's to the ordering physician and to discuss additional options for treatment. In this case in particular the patient is now stable. Hemodilution may account for some of the drop in hemoglobin. Careful observation may be all that is needed. It is never acceptable to be less than transparent with a patient regarding their treatments. Refusing to carry out an order and filing a variance report without first communicating and collaborating is less than professional nursing practice. Explaining risks and
benefits of a procedure is a part of informed consent. This is the responsibility of the provider ordering the procedure. You are caring for a 75 year old female patient admitted for severe sepsis. The patient had an extended ICU stay, several bouts of delirium, and developed a hospital associated infection. Your patient is now stable, has returned to baseline cogntiive functioning, and is progessing daily with activity. Discharge is planned for tomorrow. Your patient's recovery is an example of what patient characteristic: A. Sustainability. B. Resource availability. C. Resiliency. D. Predictability. - answer C. Resiliency is defined as the capacity to return to a restorative level of functioning using a variey of compensatory or coping mechanisms. It can also be defined as the ability to bounce back quickly after an insult, including physical illness. Patients who recover from a critical illness involving complications are demonstrating resiliency. Resource availability refers to the amount of resources (financial, social, psychological, etc) the patient and family bring to the situation. Predictability is the characteristic that allows one to expect a certain course of events. For example: A surgical patient who follows the expected clinical pathway after surgery is demonstrating predictability. Sustainability is not a patient characteristic within the synergy model. The following is true regarding the message of the Synergy Model for patient care: A. The needs of patients come first and the competencies of nurses influence outcomes. B. Synergy reqires patients to submit their needs in writing so they are transparent to the nursing staff. C. The needs of the nurse should be the driving force in making patient assignments. D. Synergy is the primary nurse competency that develops as nurses move from Novice to Expert. - answer A. The Synergy Model puts the needs of the patient front and center. When nurse competencies are applied to match the needs of patients, outcomes are improved.
