Heart Heart failure symptoms are described as shortness

Heart Failure and Nursing

Marleana Groh

University of Southern





Today, more than 6.5 million adults suffer
from heart failure. About half of those diagnosed with heart failure will die
within five years.  Heart failure care
and frequent hospital readmissions are financially overwhelming to healthcare
systems across the country. This is leading to decreased overall quality of
life for the patient. Nurses care for heart failure patients in a multitude of
settings; the hospital, outpatient clinics, and in the patient’s home.  This paper evaluates the heart failure
guidelines described by the American Heart Association, in conjunction with
evidence based practice to decrease hospital readmissions. This paper will also
expand upon nursing care of the heart failure patient, the synergy model as a
middle range theory, including an evaluation of the theory. Other topics
discussed in this paper will be the writer’s personal metaparadigm, reflecting
on the writer’s experience as a nurse and the writer’s understanding of person,
health, environment, and nurse.












Heart Failure and Nursing

Today, more than 6.5 million adults suffer
from heart failure. About half of those diagnosed with heart failure will die
within five years (National Center for Chronic Disease Prevention and Health
Promotion, 2016). Heart failure is defined as a chronic progressive condition
in which the heart cannot pump effectively to keep up with the body’s oxygen
demand. The body compensates for a period of time in patients with heart
failure, but over time as the heart weakens, the patient becomes more symptomatic
and will experience worsening symptoms. 
Heart failure symptoms are described as shortness of breath, chronic
cough, swelling of the abdomen and lower extremities, fatigue, and high heart
rate (“Warning Signs of Heart Failure,” 2017).  This paper will discuss an overview of heart
failure; evidence based practice for treatment, as well as evidence based
practice for reducing heart failure readmissions through appropriate self-care
and education. This encompasses both cost-effective care, and overall improved
quality of life. This writer has worked extensively with heart failure patients,
as the writer gained experience caring for this population, the writer saw the
importance in applying evidence based guidelines to provide better care to this
growing population.

Nurses care for heart failure patients in a
variety of settings; the hospital, outpatient clinics, and in the patient’s
home. Nurses provide more than just nursing care to heart failure patients;
they provide care and education to the patient’s families. Nurses also act as
the pillar of the multi-disciplinary team. Nurses work to ensure all of the
patient/family needs are being met and if they are not, the nurse works with
the team until a plan is implemented to meet those needs. This paper will
discuss how nurses utilize the guidelines of the synergy model to help meet
patient and family needs. This paper will also expand upon the synergy model,
discussing in depth this middle range theory along with an evaluation.  Other topics discussed in this paper will be
the writer’s personal metaparadigm, reflecting on the writer’s experience as a
nurse and the writer’s understanding of person, health, environment, and nurse.


This writer’s
personal metaparadigm focuses on the patient as a whole person. The patient’s
mental and emotional well-being are just as important as their physical. Person
is viewed as mind, body, and spirit. Family is also important to the person
component as well. Family is whoever the patient identifies as family. Health
is viewed on a continuum as a person’s health can change constantly. Health is
also what the patient says and views it as. Environment is many settings; the
intensive care unit, the progressive care unit, a clinic, or other settings. As
healthcare changes, the environment can change. It is also crucial that the
nurse be aware of the environment and make adjustments to meet the
patient/family needs. This writer’s personal metaparadigm views the nurse as a
provider of many parts in regard to the patient. The nurse is a care-giver,
educator, advocate, and facilitator. The nurse assesses the patient as a whole
(body, mind, and spirit), then assesses the environment and works to
incorporate the two to provide the best care for the patient, as well as the
family. The nurse also serves as a pillar in the interdisciplinary healthcare
team to help facilitate meeting the short and long terms needs of the patient,
as well as the patient’s family. This writer’s metaparadigm comes from many
years of critical care experience working with various critically ill
populations in a variety of settings focusing primarily on advanced heart

The AACN Synergy Theory

The Association of
Critical Care Nurses (AACN) theory was first established in the 1990’s as a way
to expand thinking about the practice of nursing beyond the view that nursing
is simply a series of tasks, moving toward a more holistic model which values
nursing as more than a sum of its parts (Peterson,
2017, p. 293). This theory’s
components are most congruent with writer’s personal metaparadigm. When
assessing the components of the metaparadigm, the synergy model refers to
person as the individual patient, however it has since been expanded to include
family and community as well (Curley,
2007, p. 225-226).  The environment is described as an intensive
care unit or acute care area. This writer’s personal metaparadigm refers to
environment as more than the intensive care or acute care area. This writer
feels that there are critically ill patients in many more areas; such as
dialysis centers and even some specialized areas such as heart failure clinics.
The synergy model refers to nurse as the individual nurse (Curley, 2007, p. 225-226). The nurse is also described
as the individual nurse’s competencies. Health is described by the synergy
model as an optimal level of wellness that can be achieved for the patient and
family (Peterson, 2017, p. 294).

The synergy model
details eight characteristics or competencies describing the nurse. They are listed
as; clinical judgement, advocacy, caring practices, collaboration, response to
diversity, clinical inquiry, facilitator of learning, and systems thinking (Peterson, 2017, p. 296-297). This correlates with the
writer’s personal metaparadigm, the writer feels that the nurse is more than a
care-giver, that the nurse is a vital component to the multidisciplinary team.
Patient care has many facets both situational and environmental, the nurse
encompasses the ability to assess those and incorporate their own growth and
experiences to provide comprehensive care to the patient as well as their
families. The nurse is able to adjust the environment or situation to ensure it
can promote maximum comfort and healing to the patient.

The AACN Synergy
Model is considered a middle range theory. Middle range theory is comprised of
the four elements of the nursing paradigm. It is narrower in scope compared to
grand theory. Middle range theory is easier to operationalize and implement in
to nursing practice (Bonham, 2017). This theory was developed to improve
patient outcomes in regard to safety and overall well-being. It was also
developed to increase nurse satisfaction by recognizing their accomplishments
as competencies. This model explains that matching the patient characteristics
with the nurse’s competencies, creates “synergy”, by optimizing patient
outcomes (Peterson, 2017 p. 296). The Synergy Model expands framework that goes
on to describe characteristics of the patient that present concerns to the
nurse. Those patient characteristics are listed as; resiliency, vulnerability,
stability, complexity, resource availability, participation in care,
participation in decision making, and predictability (American Association of
Critical Care Nurses, p. 2-3). As the nurse assesses each patient using the
above described characteristics, the nurse is reflecting on their own
experience and clinical competencies. These eight competencies take integration
of knowledge, skills, experience and attitudes to meet the patient/family needs.
The Synergy Model outlines nurse characteristics or competencies as the
following; clinical judgement, advocacy and moral agency, caring practices,
collaboration, systems thinking, response to diversity, facilitator of
learning, and clinical inquiry (American Association of Critical Care Nurses,
p. 4-6). As the complexity of the patient increases,  higher levels of nurse competencies are needed
to care for the more complex patient. When evaluating internal criticism of
this theory, it can be broken down as the following:


There are
assumptions that guide the Synergy Model. They are viewed as the following;
patients are biological, psychological, social and spiritual entities. The
whole patient (body, mind, and spirit) are to be considered (American
Association of Critical Care Nurses, p. 2). Other assumptions are the patient,
family, and community contributes to the foundation of the nurse/patient
relationship. Both the patient and the nurse can be described by a number of
characteristics. The Synergy Model recognizes them as being interrelated and
unable to be isolated on either side (nurse or patient). The goal of nursing is
to restore the patient to an optimal level of wellness that is defined by the
patient. The Synergy Model recognizes death as an acceptable outcome, however,
the goal changes to ensure the patient moves toward a peaceful death (American
Association of Critical Care Nurses, p.1).


The Synergy Model
requires some clarity due to a lack of definitions with specific outcomes. It
makes the assumption a less critical patient requires a less competent nurse,
this requires clarification as well. It is clear, however, when it comes to
describing all of the main components. The components of the synergy model are
consistent in terms of compatibility of model components, model concepts and
philosophical bases (Curley, 2007, p. 223-226). The AACN is clear in their
goals for the development of the Synergy Model. The Synergy Model is adequate
in terms of relation to the four components of the nursing metaparadigm, it is
adequate in the scope in which it is meant to me implemented (ICU) as well as
it is reflective in current nursing realities. The Synergy Model can be
utilized in multiple critical care settings in any hospital. It also can be
utilized as a way to measure patient characteristics, as well as, nurse
competencies. Nurses can utilize this model to track their own growth and
development as well as use it as an assessment model for their individual
patients (Becker, et al., 2006, p. 131).


theory is consistent throughout, uses similar terminology when describing
patient characteristics, as well as nurse competencies. Multiple sources
reviewed to write this paper use similar to identical language to describe the
theory and its components (such as the AACN, Peterson, & Curley).

Logical Development

development of this theory is logically consistent. It goes on to describe the
fundamental operations and procedures that support a strong argument that when
nurse competencies and patient needs are matched, optimal outcomes are
achieved. It is logical in the sense that having a nurse that is competent in
skills needed for evaluation, intervention, and assessment of a patient with
specific characteristics (outlined in the model), will result in the best
possible patient outcome. It is also logical that if the nurse did not have the
competencies to match the patient, the outcome may not be as optimal (Curley,
2007, p. 223-226).

Clinical Issue

Medical treatment for heart failure costs
upwards of 30 billion dollars each year in the U.S. alone. The total number of
heart failure patients is expected to rise to more than 8 million by 2030 (The
American Heart Association, 2017). As these numbers rise, it is imperative for
healthcare providers to look at ways to decrease hospital admission rates,
promote self-care, provide adequate patient education with appropriate
resources, as well as promoting optimal quality of life. The American Heart
Association rolled out 2013 (updated in 2017) evidence based practice
guidelines to ensure healthcare providers, beyond those in cardiology, can
ensure proper management of heart failure. Further discussion and research from
physicians, clinical nurse specialists, nurse practitioners, and other health
care professionals have laid foundational work to empower the entire healthcare
team to provide a multi-disciplinary approach to caring for heart failure. The
writer has always cared for heart failure patients in particular; whether they
were admitted for new onset diagnosis, acute exacerbation, or advanced care
such as ventricular assist devices or cardiac transplant. As the writer has
gained experience as nurse, the writer utilized the competencies outlined by
the synergy model, enabling the writer to better care for complex patients
suffering from various stages of heart failure. This same experience, along
with the writer’s personal experience, helped create the writer’s personal
metaparadigm, ensuring the writer provides competent, compassionate care to
patients as well as their families.

Evidence Based Practice

guidelines are provided by the American College of Cardiology (ACC), the
American Heart Association (AHA), and the Heart Failure Society of America
(HFSA), providers can utilize these guidelines to ensure their patient is being
treated with the latest medical advances, being both medication or device (Yancy, et al.,2016, p. 295-296).

            Despite proper medication management
and aggressive treatment, heart failure is one of the top reasons for hospital
admissions with subsequent readmissions, approximately 18 per 1000 (Horwitz
& Krumholz, 2016). With, at times, limited resources and hospital
reimbursement rates, it is important to look at being both financially
responsible and empowering the patient and family to have a better
understanding of heart failure management. Evidence based practice has shown
this can be done through a multi-disciplinary approach providing encompassing
care, including; treating root causes of heart failure, comorbidities, and
improving the management of care (Horwitz and Krumholz, 2016). These are
reflected in the AHA guidelines under “Coordinating Care for Patients with
Chronic Heart Failure” (Yancy, et al.,2016, p. 295-296). 
Treatment must also extend from more than the inpatient hospital
admission. Readmissions have been shown to decrease if patients have follow up
in outpatient clinics and/or home visits from an APRN or nurse. Other
strategies included frequent telephone follow up that included medication
changes as needed, overall these interventions prevented emergency room visits
and readmissions (Kim & Han, 2013, p. 225). These interventions also
decreased patients overall heart failure symptoms and improved quality of life.

Implications for Practice

reviewing the Synergy Model content as outlined above. The model was
established to articulate the competencies brought to patient care by nurses,
meeting the needs of both patient and families (Peterson, 2017, p. 292). This
model encourages that nursing reflects the knowledge, skills, experience, and
attitudes to meet the patient’s needs (Curley, 2014, p. 226). The synergy model
outlines eight nurse competencies; clinical judgement, advocacy, clinical
practice, collaboration, response to diversity, clinical inquiry, facilitator
of learning, and systems thinking (Peterson, 2017). Nurses working in heart
failure utilize these competencies to promote optimal patient outcomes. They
work within the interdisciplinary team to review the American Heart Association
(AHA) guidelines for heart failure management; within their scope of practice
they can implement interventions, utilizing their clinical judgment (Albert,
2006, 172).  Nurses putting these
practices in place will improve meeting the needs of the heart failure patient.
Heart failure patients can be complex requiring diverse needs, that not only
affect patients, but their caregivers.
According to one study (Ryan, Aloe, & Mason-Johnson, 2009), nurses were
given evidence based practice guidelines as described by the AHA for managing
compliance of heart failure patients. These consisted of reviewing daily
self-care activities, daily weights, the importance of medication compliance,
follow up information, and symptom management. Bedside nurses were given an
hour to educate their patients and care givers on this information. This was
found to improve patient and caregiver understanding of heart failure
education. The results reflected increased patient satisfaction, the patient
and care-giver felt more prepared when discharged home. The results also
displayed the association with education and decreased hospital readmission
rates. Synergy model practice is
driven by the characteristics and needs of the patient (Peterson, 2017). This
is empowering information for nurses caring for heart failure patients.  Nurses are facilitators of learning and
utilize caring practice; they can take knowledge acquired through experience to
promote self-care in patients both newly diagnosed and those who have had heart
failure for an extended period of time. Through advocacy nurses can assist in
assuring additional needs are being met. The synergy model promotes this
through a multi-disciplinary approach, including, social work, case management,
and palliative care. Utilizing clinical inquiry and systems thinking, the nurse
is able to ensure the heart failure patient and their care givers are given the
tools to live out an optimal quality of life. Using the current best practice
guidelines and integrate this into a caring, holistic approach.


Heart failure affects many individuals in all
socioeconomic statuses. It is imperative to take an all hands-on deck approach
utilizing streamlined resources presented by the heart failure experts, to
ensure all heart failure patients are getting appropriate treatment. Decreasing
readmission rates decreases costs to the patient, as well as the hospital.
Nursing care today is an amazing utilization tool to help facilitate this
movement. Heart failure is a disease
that will not be dissolving anytime soon, however, through evidence based
practice, a multi-disciplinary approach, and education, patients can live out
an optimal quality of life. As nurses continue to care for heart failure
patients, they can utilize the competencies provided by the synergy model in
conjunction with their own clinical judgement along with utilizing the AHA
guidelines to provide the best care to heart failure patients. By following
these specifications not only are patients receiving the best heart failure care,
they have a better understanding of their disease and disease management, thus
helping to decrease readmission rates and keeping costs of care fiscally



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