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Heart Failure and NursingMarleana GrohUniversity of SouthernIndiana   AbstractToday, more than 6.

5 million adults sufferfrom heart failure. About half of those diagnosed with heart failure will diewithin five years.  Heart failure careand frequent hospital readmissions are financially overwhelming to healthcaresystems across the country. This is leading to decreased overall quality oflife for the patient. Nurses care for heart failure patients in a multitude ofsettings; the hospital, outpatient clinics, and in the patient’s home.  This paper evaluates the heart failureguidelines described by the American Heart Association, in conjunction withevidence based practice to decrease hospital readmissions. This paper will alsoexpand upon nursing care of the heart failure patient, the synergy model as amiddle range theory, including an evaluation of the theory. Other topicsdiscussed in this paper will be the writer’s personal metaparadigm, reflectingon the writer’s experience as a nurse and the writer’s understanding of person,health, environment, and nurse.

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           Heart Failure and NursingToday, more than 6.5 million adults sufferfrom heart failure. About half of those diagnosed with heart failure will diewithin five years (National Center for Chronic Disease Prevention and HealthPromotion, 2016). Heart failure is defined as a chronic progressive conditionin which the heart cannot pump effectively to keep up with the body’s oxygendemand. The body compensates for a period of time in patients with heartfailure, but over time as the heart weakens, the patient becomes more symptomaticand will experience worsening symptoms.

 Heart failure symptoms are described as shortness of breath, chroniccough, swelling of the abdomen and lower extremities, fatigue, and high heartrate (“Warning Signs of Heart Failure,” 2017).  This paper will discuss an overview of heartfailure; evidence based practice for treatment, as well as evidence basedpractice for reducing heart failure readmissions through appropriate self-careand education. This encompasses both cost-effective care, and overall improvedquality of life. This writer has worked extensively with heart failure patients,as the writer gained experience caring for this population, the writer saw theimportance in applying evidence based guidelines to provide better care to thisgrowing population. Nurses care for heart failure patients in avariety of settings; the hospital, outpatient clinics, and in the patient’shome. Nurses provide more than just nursing care to heart failure patients;they provide care and education to the patient’s families. Nurses also act asthe pillar of the multi-disciplinary team.

Nurses work to ensure all of thepatient/family needs are being met and if they are not, the nurse works withthe team until a plan is implemented to meet those needs. This paper willdiscuss how nurses utilize the guidelines of the synergy model to help meetpatient 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 bethe writer’s personal metaparadigm, reflecting on the writer’s experience as anurse and the writer’s understanding of person, health, environment, and nurse.PersonalMetaparadigmThis writer’spersonal metaparadigm focuses on the patient as a whole person. The patient’smental and emotional well-being are just as important as their physical. Personis viewed as mind, body, and spirit. Family is also important to the personcomponent as well. Family is whoever the patient identifies as family. Healthis viewed on a continuum as a person’s health can change constantly. Health isalso what the patient says and views it as.

Environment is many settings; theintensive care unit, the progressive care unit, a clinic, or other settings. Ashealthcare changes, the environment can change. It is also crucial that thenurse be aware of the environment and make adjustments to meet thepatient/family needs. This writer’s personal metaparadigm views the nurse as aprovider 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 toincorporate the two to provide the best care for the patient, as well as thefamily. The nurse also serves as a pillar in the interdisciplinary healthcareteam 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 manyyears of critical care experience working with various critically illpopulations in a variety of settings focusing primarily on advanced heartfailure. The AACN Synergy TheoryThe Association ofCritical Care Nurses (AACN) theory was first established in the 1990’s as a wayto expand thinking about the practice of nursing beyond the view that nursingis simply a series of tasks, moving toward a more holistic model which valuesnursing as more than a sum of its parts (Peterson,2017, p. 293). This theory’scomponents are most congruent with writer’s personal metaparadigm. Whenassessing the components of the metaparadigm, the synergy model refers toperson as the individual patient, however it has since been expanded to includefamily and community as well (Curley,2007, p.

 225-226).  The environment is described as an intensivecare unit or acute care area. This writer’s personal metaparadigm refers toenvironment as more than the intensive care or acute care area. This writerfeels that there are critically ill patients in many more areas; such asdialysis 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 describedas the individual nurse’s competencies.

Health is described by the synergymodel as an optimal level of wellness that can be achieved for the patient andfamily (Peterson, 2017, p. 294). The synergy modeldetails eight characteristics or competencies describing the nurse. They are listedas; clinical judgement, advocacy, caring practices, collaboration, response todiversity, clinical inquiry, facilitator of learning, and systems thinking (Peterson, 2017, p. 296-297). This correlates with thewriter’s personal metaparadigm, the writer feels that the nurse is more than acare-giver, that the nurse is a vital component to the multidisciplinary team.Patient care has many facets both situational and environmental, the nurseencompasses the ability to assess those and incorporate their own growth andexperiences to provide comprehensive care to the patient as well as theirfamilies. The nurse is able to adjust the environment or situation to ensure itcan promote maximum comfort and healing to the patient.

The AACN SynergyModel is considered a middle range theory. Middle range theory is comprised ofthe four elements of the nursing paradigm. It is narrower in scope compared togrand theory. Middle range theory is easier to operationalize and implement into nursing practice (Bonham, 2017).

This theory was developed to improvepatient outcomes in regard to safety and overall well-being. It was alsodeveloped to increase nurse satisfaction by recognizing their accomplishmentsas competencies. This model explains that matching the patient characteristicswith the nurse’s competencies, creates “synergy”, by optimizing patientoutcomes (Peterson, 2017 p. 296).

The Synergy Model expands framework that goeson to describe characteristics of the patient that present concerns to thenurse. Those patient characteristics are listed as; resiliency, vulnerability,stability, complexity, resource availability, participation in care,participation in decision making, and predictability (American Association ofCritical Care Nurses, p. 2-3). As the nurse assesses each patient using theabove described characteristics, the nurse is reflecting on their ownexperience and clinical competencies. These eight competencies take integrationof knowledge, skills, experience and attitudes to meet the patient/family needs.

The Synergy Model outlines nurse characteristics or competencies as thefollowing; clinical judgement, advocacy and moral agency, caring practices,collaboration, systems thinking, response to diversity, facilitator oflearning, 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 neededto care for the more complex patient. When evaluating internal criticism ofthis theory, it can be broken down as the following:AssumptionsThere areassumptions that guide the Synergy Model. They are viewed as the following;patients are biological, psychological, social and spiritual entities. Thewhole patient (body, mind, and spirit) are to be considered (AmericanAssociation of Critical Care Nurses, p. 2).

Other assumptions are the patient,family, and community contributes to the foundation of the nurse/patientrelationship. Both the patient and the nurse can be described by a number ofcharacteristics. The Synergy Model recognizes them as being interrelated andunable to be isolated on either side (nurse or patient). The goal of nursing isto restore the patient to an optimal level of wellness that is defined by thepatient. The Synergy Model recognizes death as an acceptable outcome, however,the goal changes to ensure the patient moves toward a peaceful death (AmericanAssociation of Critical Care Nurses, p.1). ClarityThe Synergy Modelrequires some clarity due to a lack of definitions with specific outcomes. Itmakes the assumption a less critical patient requires a less competent nurse,this requires clarification as well.

It is clear, however, when it comes todescribing all of the main components. The components of the synergy model areconsistent in terms of compatibility of model components, model concepts andphilosophical bases (Curley, 2007, p. 223-226). The AACN is clear in theirgoals for the development of the Synergy Model. The Synergy Model is adequatein terms of relation to the four components of the nursing metaparadigm, it isadequate in the scope in which it is meant to me implemented (ICU) as well asit is reflective in current nursing realities. The Synergy Model can beutilized in multiple critical care settings in any hospital. It also can beutilized as a way to measure patient characteristics, as well as, nursecompetencies. Nurses can utilize this model to track their own growth anddevelopment as well as use it as an assessment model for their individualpatients (Becker, et al.

, 2006, p. 131).Consistency            Thetheory is consistent throughout, uses similar terminology when describingpatient characteristics, as well as nurse competencies. Multiple sourcesreviewed to write this paper use similar to identical language to describe thetheory and its components (such as the AACN, Peterson, & Curley). Logical Development            Thedevelopment of this theory is logically consistent. It goes on to describe thefundamental operations and procedures that support a strong argument that whennurse competencies and patient needs are matched, optimal outcomes areachieved. It is logical in the sense that having a nurse that is competent inskills needed for evaluation, intervention, and assessment of a patient withspecific characteristics (outlined in the model), will result in the bestpossible patient outcome. It is also logical that if the nurse did not have thecompetencies to match the patient, the outcome may not be as optimal (Curley,2007, p.

223-226). Clinical IssueMedical treatment for heart failure costsupwards of 30 billion dollars each year in the U.S.

alone. The total number ofheart failure patients is expected to rise to more than 8 million by 2030 (TheAmerican Heart Association, 2017). As these numbers rise, it is imperative forhealthcare providers to look at ways to decrease hospital admission rates,promote self-care, provide adequate patient education with appropriateresources, as well as promoting optimal quality of life. The American HeartAssociation rolled out 2013 (updated in 2017) evidence based practiceguidelines to ensure healthcare providers, beyond those in cardiology, canensure proper management of heart failure. Further discussion and research fromphysicians, clinical nurse specialists, nurse practitioners, and other healthcare professionals have laid foundational work to empower the entire healthcareteam to provide a multi-disciplinary approach to caring for heart failure. Thewriter has always cared for heart failure patients in particular; whether theywere admitted for new onset diagnosis, acute exacerbation, or advanced caresuch as ventricular assist devices or cardiac transplant. As the writer hasgained experience as nurse, the writer utilized the competencies outlined bythe synergy model, enabling the writer to better care for complex patientssuffering from various stages of heart failure. This same experience, alongwith the writer’s personal experience, helped create the writer’s personalmetaparadigm, ensuring the writer provides competent, compassionate care topatients as well as their families.

Evidence Based Practice            Treatmentguidelines are provided by the American College of Cardiology (ACC), theAmerican Heart Association (AHA), and the Heart Failure Society of America(HFSA), providers can utilize these guidelines to ensure their patient is beingtreated with the latest medical advances, being both medication or device (Yancy, et al.,2016, p. 295-296).             Despite proper medication managementand aggressive treatment, heart failure is one of the top reasons for hospitaladmissions with subsequent readmissions, approximately 18 per 1000 (Horwitz& Krumholz, 2016). With, at times, limited resources and hospitalreimbursement rates, it is important to look at being both financiallyresponsible and empowering the patient and family to have a betterunderstanding of heart failure management. Evidence based practice has shownthis can be done through a multi-disciplinary approach providing encompassingcare, including; treating root causes of heart failure, comorbidities, andimproving the management of care (Horwitz and Krumholz, 2016).

These arereflected in the AHA guidelines under “Coordinating Care for Patients withChronic Heart Failure” (Yancy, et al.,2016, p. 295-296). Treatment must also extend from more than the inpatient hospitaladmission.

Readmissions have been shown to decrease if patients have follow upin outpatient clinics and/or home visits from an APRN or nurse. Otherstrategies included frequent telephone follow up that included medicationchanges as needed, overall these interventions prevented emergency room visitsand readmissions (Kim & Han, 2013, p. 225). These interventions alsodecreased patients overall heart failure symptoms and improved quality of life.Implications for Practice Inreviewing the Synergy Model content as outlined above. The model wasestablished to articulate the competencies brought to patient care by nurses,meeting the needs of both patient and families (Peterson, 2017, p.

292). Thismodel encourages that nursing reflects the knowledge, skills, experience, andattitudes to meet the patient’s needs (Curley, 2014, p. 226).

The synergy modeloutlines eight nurse competencies; clinical judgement, advocacy, clinicalpractice, collaboration, response to diversity, clinical inquiry, facilitatorof learning, and systems thinking (Peterson, 2017). Nurses working in heartfailure utilize these competencies to promote optimal patient outcomes. Theywork within the interdisciplinary team to review the American Heart Association(AHA) guidelines for heart failure management; within their scope of practicethey can implement interventions, utilizing their clinical judgment (Albert,2006, 172).  Nurses putting thesepractices in place will improve meeting the needs of the heart failure patient.Heart failure patients can be complex requiring diverse needs, that not onlyaffect patients, but their caregivers.According to one study (Ryan, Aloe, & Mason-Johnson, 2009), nurses weregiven evidence based practice guidelines as described by the AHA for managingcompliance of heart failure patients. These consisted of reviewing dailyself-care activities, daily weights, the importance of medication compliance,follow up information, and symptom management. Bedside nurses were given anhour to educate their patients and care givers on this information.

This wasfound to improve patient and caregiver understanding of heart failureeducation. The results reflected increased patient satisfaction, the patientand care-giver felt more prepared when discharged home. The results alsodisplayed the association with education and decreased hospital readmissionrates. Synergy model practice isdriven by the characteristics and needs of the patient (Peterson, 2017).

Thisis empowering information for nurses caring for heart failure patients.  Nurses are facilitators of learning andutilize caring practice; they can take knowledge acquired through experience topromote self-care in patients both newly diagnosed and those who have had heartfailure for an extended period of time. Through advocacy nurses can assist inassuring additional needs are being met. The synergy model promotes thisthrough a multi-disciplinary approach, including, social work, case management,and palliative care.

Utilizing clinical inquiry and systems thinking, the nurseis able to ensure the heart failure patient and their care givers are given thetools to live out an optimal quality of life. Using the current best practiceguidelines and integrate this into a caring, holistic approach. ConclusionHeart failure affects many individuals in allsocioeconomic statuses. It is imperative to take an all hands-on deck approachutilizing streamlined resources presented by the heart failure experts, toensure all heart failure patients are getting appropriate treatment. Decreasingreadmission rates decreases costs to the patient, as well as the hospital.Nursing care today is an amazing utilization tool to help facilitate thismovement.

Heart failure is a diseasethat will not be dissolving anytime soon, however, through evidence basedpractice, a multi-disciplinary approach, and education, patients can live outan optimal quality of life. As nurses continue to care for heart failurepatients, they can utilize the competencies provided by the synergy model inconjunction with their own clinical judgement along with utilizing the AHAguidelines to provide the best care to heart failure patients. By followingthese specifications not only are patients receiving the best heart failure care,they have a better understanding of their disease and disease management, thushelping to decrease readmission rates and keeping costs of care fiscallyresponsible.  ReferencesAlbert, N.

 M. (2006).Evidence-based nursing care for patients with heart failure. AACN Advanced Critical Care, 17(2), 170-183.doi:10.1097/01256961-200604000-00013American Association of CriticalCare Nurses. (n.d.

). The aacn synergy model for patient care. Retrieved November 9,2017, from https://www.aacn.org/~/media/aacn-website/nursing-excellence/standards/aacnsynergymodelforpatientcare.pdf?la=enAmerican Association of Critical CareNurses. (n.

d.). Basic information about the aacn synergymodel for patient care. Retrieved fromhttps://www.

aacn.org/~/media/aacn-website/nursing-excellence/standards/aacnsynergymodelforpatientcare.pdf?la=en The American Heart Association.(2017). Top 10 things to know. Retrieved October 12, 2017,   fromhttp://www.heart.org/idc/groups/ahamah-       public/@wcm/@sop/@smd/documents/downloadable/ucm_493382.

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lib-proxy.usi.edu/docview/227859576?accountid=14752Bonham, B. (2017). Middle Range Theories Powerpoint Slides .

Retrievedfrom https://usi.blackboard.com/webapps/blackboard/content/listContent.jsp?course_id=_14854_1&content_id=_702800_1Curley, M. A. (2014).

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cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htmRyan, M., Aloe, K.,& Mason-Johnson, J. (2009). Improving self-management and reducinghospital readmission in heart failure patients. Clinical Nurse     Specialist, 23(4), 216-221.

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, …Westlake, C. (2016). 2016 ACC/AHA/HFSA Focused Updateon New Pharmacological Therapy for Heart Failure: An Update of the 2013ACCF/AHA Guideline for the Management of Heart Failure. Journal of the American College ofCardiology, 68(13),1476-1488. doi:10.1016/j.jacc.2016.05.011