Using the Synergy Model to Provide Spiritual Nursing Care in ...

ClinicalArticle
Using the Synergy Model
to Provide Spiritual Nursing
Care in Critical Care Settings
Amy Rex Smith, DNSc, APRN, BC
Aresurgence of interest in
spirituality is evident in postmodern
culture. 1 This interest has not been
limited to popular culture alone;
scientific interest in the effects of
spirituality and religion on health
has been gaining momentum since
the 1980s. A search of the term “spiritual
care” in the CINAHL database
yielded only 293 articles for the
period 1982 to 1994, and 1106 articles
for the period 1995 to 2005. Taylor
2 reported that a mid-2004 search
of PubMed yielded 202 clinical trials
in which religion was a study
variable, 30 000 articles on religion,
and 1500 articles on spirituality and
that more than 12 nursing textbooks
on spiritual care had been published
since 1989.
A consensus is growing that religiosity
and spirituality are significantly
related to physical and
psychological health 3 and that the
scientific study of spirituality and
health is an important focus of nursing
research. 4,5 Concerns about the
quality of the methods used in
research on spirituality and religion
are ongoing. 3 Despite the resurgence
of spirituality as a legitimate focus
for nursing research, little data-based
information specific to spirituality
and critical care nursing practice is
available.
In this article, I identify challenges
of providing spiritual care in
critical care settings, explain how
the elements of the American Association
of Critical-Care Nurses
(AACN) Synergy Model for Patient
Care 6 address spirituality, and recommend
nursing interventions
based on the Synergy Model that are
targeted to critically ill patients’
spiritual needs.
Author
Amy Rex Smith is an associate professor in the Department of Nursing, College of Nursing
and Health Sciences, University of Massachusetts, Boston, Mass.
Corresponding author: Amy Rex Smith, DNSc, APRN, BC, Department of Nursing, College of Nursing and Health
Sciences, University of Massachusetts Boston, 100 Morrissey Blvd, Boston, MA 02125 (e-mail:
amyrex.smith@umb.edu).
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
What Is Spirituality?
Scholars are seeking to clarify
spirituality as a concept for use in the
health sciences. 7 Authors 3,5,7-9 generally
agree that the concept of spirituality
is broader than the concept of
religion. Religious beliefs and practices
can be expressions of spirituality,
but spirituality exists apart from
religion. 5,8 The consensus is that spirituality
is defined as the manner by
which persons seek meaning in their
lives and experience transcendence—
connectedness to that which is beyond
the self—whereas religion is best
understood as adherence to an
accepted formalized system of belief
and practices. 5,8,9 Most nurse authors 8,9
view spirituality as a universal phenomenon,
for although all persons
do not understand and accept the
supernatural, all persons have needs
for seeking meaning and acceptance
in their lives.
Although spirituality is an abstract
and multidimensional concept, 5,8-10
2 components of spirituality are widely
described: vertical and horizontal.
The vertical component describes
that which is transcendent, the connections
between a patient (inside
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the body) and something outside of
the patient: God, the divine, or a
higher power (upward or out there
somewhere). 9-11 The horizontal component
addresses the connections
between persons. Connections
between persons are generally understood
as personal and social support
that is embedded in the spiritual context
and provided by religious settings
and spiritual relationships. 9-11
Spiritual care is defined as the
provision of interventions in the
domain of spirituality and has long
been the focus of hospital chaplains. 12
Spiritual care also has been accepted
as a legitimate focus of nursing practice.
The North American Nursing
Diagnosis Association has 2 accepted
nursing diagnoses for spirituality:
spiritual distress and readiness for
enhanced spiritual well-being. 13,14
The Nursing Outcomes Classification
includes 20 indicators for spiritual
health, and the Nursing Interventions
Classification includes 4 specific interventions
for spiritual care—religious
ritual enhancement, spiritual support,
spiritual growth facilitation, and forgiveness
facilitation—and 2 more
general interventions that are often
used in spiritual care: bibliotherapy
with sacred texts and presence. 13,14
Spiritual Nursing Care
in Critical Care Settings
Critical care nursing is a demanding
specialty that requires advanced
knowledge of physiology and highly
technological interventions. Nurses
care for critically ill patients in intensive
care units (ICUs) and progressive
care units. Because the acuity of hospitalized
patients has increased, some
authors 15 claim that all hospital nursing
care has become critical care.
Patients in critical care units are the
most seriously ill and injured among
all hospitalized patients.
ICUs house patients who are the
sickest and in the most unstable condition,
patients whose physiological
needs predominate. The culture of
critical care units is created by staff
interaction around the competing
demands of treating multiple lifethreatening
and complex problems
in a fast-paced environment. 16 Fontaine
17 identifies the purpose of ICUs
as places to provide monitoring of
the sickest patients in the hospital
and convincingly describes the difficulties
of creating healing environments
in ICU settings. The issue of
environment is so important that the
AACN has identified creating healing
humane environments as a research
priority. 18 One of the 2 platforms of
the new AACN standards on healthy
work environments is that work and
care environments must be safe,
healing, and humane and respectful
of the rights, responsibilities, needs,
and contributions of patients, patients’
families, nurses, and all health professionals.
19 Although critical care
units are a challenging location for
spiritual care, such care can be a way
to enhance the healing and humanity
of the highly technical, physiologically
driven ICU environment.
Spirituality and the AACN
Synergy Model for Patient Care
The AACN Synergy Model (see
Sidebar 1) is emerging as the accepted
standard conceptual framework for
acute care and critical care nursing. 6(pxi)
The first of the 5 assumptions
underlying the model is that each
patient is a whole person: body, mind,
and spirit. 6(p7) This assumption means
that each patient is more than the
pressing physiological needs that
caused hospitalization for the critical
illness. Nursing care of the whole
person, guided by the Synergy Model,
addresses not only physiological care
but also care in the psychosocial (care
of the mind) and spiritual (care of
the spirit) domains. The inclusion of
spirit as a central aspect of the AACN
Synergy Model makes this nursing
model a particularly useful guideline
for providing spiritual care in ICUs.
Indeed, use of the Synergy Model
may help nurses overcome some of
the constraints to spiritual care in
hospitals identified by Van Dover and
Bacon 20 : priority placed on physical
health needs, multiple demands on
nurses’ time, and varying expectations
of nurses and healthcare institutions
concerning the nurses’ role in giving
spiritual care.
Sidebar 1
Suggestions for Further Reading
About the Synergy Model
Relf M, Kaplow R. Critical care nursing
practice: an integration of caring,
competence, and commitment to
excellence. In: Morton PG,
Fontaine DK, Hudak CM, Gallo
BM, eds. Critical Care Nursing. 8th
ed. Philadelphia, Pa: Lippincott
Williams & Wilkins; 2005:6-8.
This chapter in a standard critical care
textbook provides a succinct clear
explanation of the Synergy Model that
is skewed toward critical care nursing.
Hardin SR, Kaplow R. Synergy for Clinical
Excellence: The AACN Synergy
Model for Patient Care. Boston,
Mass: Jones & Bartlett Publishers
Inc; 2005.
This book provides an in-depth explanation
of the Synergy Model by providing
a chapter on each feature of the
model and focuses on application by
discussing examples from a variety of
patient care specialties and situations.
42 CRITICALCARENURSE Vol 26, No. 4, AUGUST 2006 http://ccn.aacnjournals.org

The Synergy Model identifies 8
characteristics of nurses and 8 characteristics
of patients within the hospital
environment. The key to care is
the relationship between nurses and
patients, so that nurses’ competencies
coincide with patients’ needs. The
model is termed the Synergy Model
because it posits that by matching
nurses’ competencies to complement
patients’ characteristics, something
more than the sum of the parts ensues
and synergy occurs. Four areas of
the model can be related to spiritual
care: 2 characteristics of patients—
resiliency and resource availability
—and 2 characteristics of nurses—
caring practices and response to
diversity.
Patients’ Characteristics
Related to Spirituality
Resiliency
The characteristic of resiliency in
patients is defined as the “capacity to
return to a restorative level of functioning
using compensatory coping
mechanisms” 6(p14) ; the ability to bounce
back quickly after an injury. At the
lowest level of resiliency (minimally
resilient), a patient is unable to mount
a response, has “failure of compensatory/coping
mechanisms and
minimal reserves, and is brittle; . . .
at the highest level (highly resilient),
the patient is able to mount and
maintain a response and has intact
compensatory/coping mechanisms,
strong reserves, and endurance.” 6(p14)
Interventions to strengthen a
patient’s resiliency can be categorized
as belonging to the vertical
component of spirituality. Prayer is a
communication used to make a connection
between human beings and
God and is recognized as a coping
mechanism. 21 Prayer is reported to
be one of the most frequently used
complementary and alternative
medicine techniques. 22,23 Studies of
spirituality in hospitalized patients
often have indicated that prayer is a
coping mechanism. 24-27 In a study of
100 patients hospitalized the night
before open heart surgery, Saudia
et al 25 found that 96 of the patients
prayed and 2 had others pray for
them; only 2 had no prayer. Internal
reserves are reserves that are available
to be called on in times of need.
These reserves can be of great depth,
are often beyond rational explanation,
and are available in time of need. For
example, Arslanian-Engoren and
Scott 26 conducted a phenomenological
study of 7 self-identified spiritual
patients who had experienced tracheostomy
for prolonged mechanical
ventilation (mean length of stay 37
days, SD 14 days). All of the patients
found comfort through religion and
spent much time in daily prayer. The
patients also derived reassurance and
support from visions of dead relatives
and angels; in these encounters the
patients reported that they received
guidance and encouragement.
Spirituality also can provide
reserves that enhance endurance. In
a qualitative research study of men
hospitalized with prostate cancer,
Walton and Sullivan 27 applied the
metaphor “men of prayer” because
all of the patients identified the use
of prayer as vitally important. The
patients reported that prayer provided
strength, assurance, comfort,
and inner strength. Walton and Sullivan
27 also identified 2 concepts,
trusting and living day by day;
meanings ascribed to the 2 concepts
indicated endurance through difficult
illness, treatments, and
unknown outcomes.
Resource Availability
The characteristic of resource
availability in patients is influenced
by the “extent of resources brought
to the situation by the patient, family,
and community.” 6(p34) Resources are
technical, fiscal, personal, psychological,
social, or supportive. At the
lowest level, resources are few, personal/psychological
support is minimal,
and access to social systems is
minimal. At the highest level, patients
have access to many resources. The
Synergy Model posits that the more
resources, the greater is the potential
for a positive outcome; with less
resource availability, the potential
exists for a more constrained recovery
process. 6(p34)
The horizontal component 9-11 of
spirituality, the direction symbolizing
the connections between persons,
contributes directly to a patient’s
resource availability. Persons connected
to a religious congregation
may have the potential for greater
resources. Both personal support
and social support are often provided
by fellow congregants. Personal
support for patients who are congregants
comes from the patients’ ongoing
relationships with clergy, who
provide formal pastoral care. 12 Also,
many congregations have parish
nurses (recently renamed faith community
nurses) who provide spiritual
and other nursing care to ill congregants.
28(pp200-202) Social support comes
from congregations that function as
de facto social service organizations.
The tradition of service found in many
faiths, the doing of good works for
spiritual gains, can be extended to ill
congregants.
Connection to a religious congregation
is not required, however, for
enhancing the availability of spiritual
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esources. Many spiritual persons
are not members of religious groups
but do have ongoing, long-term spiritual
companions who provide guidance
for spiritual growth. 29 Spiritual
companions is a newer iteration of
the traditional “spiritual director,” a
more mature person who takes on
the responsibility for the formation
of spirituality. This relationship is a
formal one in which the focus is spiritual
growth. These spiritual relationships
provide excellent sources of
personal and social support in times
of crisis.
Nurses’ Characteristics
Related to Spirituality
Caring Practices
The purpose of caring practices
is to promote comfort and healing
and prevent unnecessary suffering. 6(p71)
Caring cannot occur without respect
for each patient as a person who has
unique needs. Nursing interventions
embedded in caring promote a healing
environment. Caring practices
acknowledge the give and take
between nurses and patients, in which
mutuality is part of the relationship.
Caring for the entire patient as a
person includes care of the spirit. In
a study of 10 critical care nurses,
Kociszewski 30 identified a “mutual
knowing” between patients and the
nurses that led to what she called “a
bridge” for spiritual assessment. This
mutual knowing began with the
nurses’ personal spirituality and built
on the nurses’ knowledge of spiritual
care. Over time, the nurses explored
the spiritual needs of the critically ill
patients and the patients’ families
and looked for overt and covert cues.
These cues were often subtle and
included photos, artifacts, a visitor
praying with a patient, and so on.
The connections between the nurses
and the patients became bridge building
for effective spiritual assessment.
Nowhere in nursing is caring more
evident than in end-of-life care, which
has emerged as an area of concern in
the ICU. In a recent study, the Robert
Wood Johnson Foundation convened
a critical care end-of-life peer work
group and added to the scholarly
group 15 physician-nurse teams who
worked together in 15 ICUs across
the United States. Spiritual support
for patients and patients’ families
emerged as one of the identified
interventions. The working group 31
identified 3 actions as indicators of
the quality of spiritual support:
1. assess and document spiritual
needs of patients and patients’ families
on an ongoing basis;
2. encourage access to spiritual
resources; and
3. elicit and facilitate spiritual
and cultural practices that patients
and their families find comforting.
These quality indicators were
identified specifically for end-of-life
care, but they also are appropriate
caring practices for all patients in
critical care units.
Response to Diversity
The characteristic of response
to diversity in nurses is defined as
the sensitivity to “recognize, appreciate,
and incorporate differences
(in patients) into the provision of
care.” 6(p93) The Synergy Model identifies
spiritual beliefs as one of the
differences to be addressed. Development
of sensitivity among nurses
is an important aspect of this characteristic.
In 2002, the AACN practice
analysis task force expanded the initial
5 assumptions underlying the
Synergy Model by adding “the nurse
brings his or her background to each
situation, including various levels of
education/knowledge and skills/experience.”
6(p8) This assumption is demonstrated
by nurses who bring their own
spirituality to the nurse-patient relationship.
In an exploration of the
attributes of spiritual care in nursing
practice, Sawatzky and Pesut 32 provided
a definition of spiritual nursing
care that simultaneously highlights
this assumption and focuses on
patients’ diversity: “Spiritual nursing
care is the intuitive, interpersonal,
altruistic, and integrative expression
that rests on the nurse’s awareness of
the transcendent dimension yet
reflects the patient’s reality.” 32(p23)
Kociszewski identified the concept
of “the spiritual nurse,” 33(p136) a label
she gave to nurses who had developed
a “spiritual self.” These nurses
indicated that they were on a spiritual
journey or pilgrimage and that
“being spiritual was the first step in
giving spiritual care.” 31(pp136-137) The
idea that nurses with self-awareness
of the spiritual realm are better prepared
to provide spiritual care than
are nurses without such awareness is
well supported. 23,34,35 A spiritual nurse
brings the experience and knowledge
of the spiritual self into the critical
care setting and is particularly adept
at meeting patients’ spiritual needs.
It is not expected that every nurse
is or should be a spiritual nurse. Studies
35,36 of hospital nurses have identified
2 types of nurses: those who
think that it is not within the purview
of nursing to provide spiritual care
and those who lack education in
spirituality. Specialized education in
spirituality can help ensure that nurses
are aware that spiritual care is within
the purview of nursing and can prepare
all nurses to deliver an appro-
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priate level of spiritual care to patients.
The following suggestions for nursing
interventions provide guidelines
for appropriate spiritual nursing care.
Suggestions for Interventions
The Synergy Model can be used
to organize and guide 5 nursing
interventions.
Caring Practices:
Accurately Identify Spiritual Needs
Being listened to and cared for
are basic needs of all patients and
their families in the environment of
the ICU. When performing nursing
assessments, nurses should identify
cues specific to the spiritual realm
and should collect data to identify
spiritual needs. Ongoing assessment
is essential, because spiritual concerns
can arise during hospitalization.
In-service training or
continuing education and support
are needed if staff nurses are to
develop expertise in spiritual assessment.
The Joint Commission on
Accreditation of Healthcare Organizations
37 has established that as a
minimum, each hospitalized
patient’s denomination, beliefs, and
spiritual practices should be
assessed and has made suggestions
for additional questions to be used
in a spiritual assessment (see Sidebar
2). Two especially detailed and
comprehensive nursing guides for
spiritual assessment are offered in
spiritual care texts by O’Brien 28 and
Taylor. 39 Assessing spiritual needs
includes identifying patients who
do not want any spiritual care, a
step that is important inasmuch as
studies of hospitalized patients
indicate that one third of patients
do not desire spiritual care while
hospitalized. 40
Response to Diversity:
Make Congruent Matches
Using the Synergy Model to
assign patients to nurses ensures
that congruent matches will be
sought. Once a patient and the
patient’s family have been identified
as needing and desiring spiritual
care, a match can be sought with a
nurse who is known for attending to
spirituality. Ideally, the nurses with
spiritual expertise are as well known
on the unit as are nurses with
expertise in weaning, handling a
new trauma patient, or dealing with
a difficult family. Making these
assignments on the basis of spirituality
will become just as routine as
looking for good fits in physiological
and psychosocial areas of the
model.
Support Resiliency:
Make Appropriate Referrals
For critical care nurses, the
pressing priority is physiological
care; spiritual care often happens
in-between and while delivering
other nursing care. Consultation
and referral to the hospital chaplain
and/or a patient’s own clergy or
spiritual companion and making
space and time for the patient and
the chaplain, clergyperson, or companion
to be together privately
helps support the vertical component
of the patient’s spirituality.
Support Resiliency: Make Space and
Time for Group and Individual
Religious Rituals and Spiritual
Practices
An appreciation for the practices
of a patient’s faith is actualized
by prioritizing time and providing
space for sacred ritual in the hospital
environment. A patient may
Sidebar 2
Suggestions for Spiritual
Assessment
Initial screening questions*
Are there any religious or spiritual
practices that would be helpful to you
while you are here?
Would you like to see a chaplain?
Additional screening questions †
What can I do to support your faith
or religious commitment?
Are there aspects of your spirituality
that you would like to discuss?
Would you like to discuss the spiritual
or religious implications of your
hospitalization?
Other questions ‡
Who or what provides you with
strength and hope?
Do you use prayer in your life?
How you express your spirituality?
What type of religious/spiritual support
do you desire?
What role does the church/
synagogue/mosque in your life?
How does your faith help you cope
with illness?
*Based on the nursing assessment form at the
Brigham and Women’s Hospital, Boston, Mass.
†As suggested by Clark et al. 38
‡As suggested by the Joint Commission on
Accreditation of Healthcare Organizations. 37
need to have uninterrupted time for
spiritual reading or prayer; a church
group may need to offer a sacred
song or a blessing. In some faiths, a
patient may need a connection with
nature, such as being able to look
out a window or see the sun rise or
set. This nursing intervention is a
simple but important one that cannot
be overemphasized.
Support Resource Availability:
Make Connections Between Patients
and Their Spiritual Support Systems
If appropriate, critical care visitation
can be extended to the members
of a patient’s congregation.
When fellow congregants cannot
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visit patients, the congregants can
often visit the patients’ families in
the waiting room and support the
families. Many congregations have
videotapes of worship services;
opportunities and equipment for
patients to watch tapes can be provided.
Flower delivery by congregants
is the traditional mark of
religious visitation; when flowers
are not permitted, small symbolic
religious gifts may be brought.
Other ways to make connections
can be individualized to meet
patients’ needs.
Specific spiritual nursing interventions
are presented in the 2 case
studies. Case 1 focuses on supporting
resiliency by making space and time.
Case 2 focuses on caring practices
when a spiritual nurse is able to
accurately identify a spiritual need.
Conclusions and Summation
A key feature identified by the
Synergy Model is the relationship
between nurses and patients, so that
nurses’ competencies coincide with
patients’ needs. Assigning nurses
with expertise in spiritual care to
patients who have spiritual needs
results in synergy. Also important
are appropriate referrals, because
nurses often cannot provide all of
the spiritual care that is needed.
Making time and space for the practice
of religious rituals at the bedside
is important and is often overlooked
as a nursing intervention.
Using the Synergy Model as a basis
for research on spiritual care in the
critical care setting is needed, especially
monitoring the frequency and
quality of spiritual assessments. Synergy
can be studied by examining
assignments of patients to nurses
and patients’ outcomes. Referrals can
Case 1: Supporting Resiliency by Collaborating With a
Chaplain and Making Time and Space for Religious Ritual
I was working the evening shift on the medical intermediate care unit at a large urban
hospital, where I have been a per diem staff nurse for more than 10 years. I was caring for an
elderly man with end-stage lung disease who was critically ill with a severe pneumonia, had
borderline values on arterial blood gas analysis, and was chronically on the verge of needing
intubation. The on-call hospital chaplain, an ordained Protestant woman, was following up
on the patient’s request from earlier in the day to receive the “sacrament of the sick.” She asked
if the priest had visited. This question was the first I knew of the request and the first indicator
I had of the patient’s Roman Catholic faith. Although I had cared for the patient the day
before, his room had had no visual cues that indicated a faith commitment, and I had been so
busy caring for his physiological needs that I did not even think about his spiritual needs. The
chaplain and I determined that the priest had not yet visited, and she went to find him.
When the priest arrived, I was in the middle of a critical physiological procedure. My
previous practice would be to ask the priest to “go away and come back at a more convenient
time.” But, because I had recently begun to understand what a sacrament meant to a
patient of this faith, I asked the priest to wait a few minutes, and I prioritized making
arrangements for the space, time, and privacy for the sacrament to occur between priest
and patient. The patient was visibly less anxious after the religious ritual, and his tachypnea
and oxygen saturation values were stable for the rest of the shift. Indeed, he recovered
from his pneumonia without needing intubation.
This appreciation for the practices of another’s faith can be generalized to all faiths.
Case 2: Caring Practices, or an Intensive Care Unit Patient
Needs a “Spiritual Nurse”
It was shortly after morning report, and I was checking on a student caring for an elderly
widow, a postoperative patient in the surgical intensive care unit. I was a clinical
instructor teaching seniors in a large teaching hospital in Southern California, and I had 8
students spread out over 4 critical care units. The student told me, “I don’t understand
what is going on with my patient; in report they said she had delirium, and she is constantly
mumbling and won’t open her eyes when I try to speak to her.”
I entered the room and found the patient with the usual postoperative invasive
catheters, monitoring equipment, and drainage tubes. She was lying on her back with her
eyes closed, and she had her hands clasped against her chest. She was mumbling, and did
not appear to hear me when I spoke to her. I touched her arm and bent down to listen, and
I heard her reciting the words of the 23rd Psalm, using the old English words of the King
James Version: “Yea though I walk through the valley of death, I shall fear no evil, for Thou
art with me . . .” I joined in her recitation: “Thy rod and thy staff they comfort me . . .”
We finished reciting the Psalm together, and she opened her eyes and looked at me expectantly.
I said, “Sometimes it really helps to say the words aloud,” and she said “I’ve been
praying and praying, but I feel all alone here.”
We went on to have a conversation about her surgery and her perceptions of the intensive
care unit. I stayed with her for several minutes and was able to ascertain that she was without
family and was scared. She had been reciting the words of the Psalm in an effort to prove to
herself that she was not alone. I was able to make arrangements for the hospital chaplain to
visit. The hospital chaplain, in addition to being present and giving spiritual care, was able to
contact the patient’s pastor and church friends, who came in and lent their support.
This situation was one in which personal knowledge of the King James Version of the
Bible led to the ability to recognize what the patient was doing and to connect with her by
reciting the Psalm together. This activity led to the identification of her isolation. Although
this experience was based in Christianity, the learning is applicable for other situations. I am
now more sensitive to a cue of a recited prayer or sacred text passage. For example, if I had a
Muslim patient reciting the Koran in Arabic, I might not recognize it and would not be able
to join in. But because of the experience described here, I would suspect the potential use of
prayer and sacred text and ask a Muslim chaplain or colleague to assess the situation.
46 CRITICALCARENURSE Vol 26, No. 4, AUGUST 2006 http://ccn.aacnjournals.org

e tracked, as can presence or absence
of rituals in the setting. In addition,
studies of spiritual care education
for staff nurses, documented with
pretesting and posttesting, would be
a valuable contribution. Sources of
spiritual care education include formal
courses offered by faith-based
universities and online resources
provided by nursing specialty organizations
such as the Oncology Nursing
Society and Association of
Nurses in AIDS Care.
Creating a humane healing environment
in the hospital is a challenge;
creating the environment for healing
is especially difficult in the ICU. Spiritual
care, within the context of the
Synergy Model, can make important
contributions to a healing environment
and theory-based nursing care.
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