Professional Documents
Culture Documents
Synergy For Clinical Excellence The Aacn Model Patient Care 2nd
Synergy For Clinical Excellence The Aacn Model Patient Care 2nd
SECOND EDITION
Edited by
Sonya R. Hardin, PhD, NP-C, RN, CCRN
Professor
College of Nursing
East Carolina University
Greenville, North Carolina
Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are avail-
able to corporations, professional associations, and other qualified organizations. For details
and specific discount information, contact the special sales department at Jones & Bartlett
Learning via the above contact information or send an email to specialsales@jblearning.com.
Copyright © 2017 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form,
electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system,
without written permission from the copyright owner.
The content, statements, views, and opinions herein are the sole expression of the respective authors and not that of
Jones & Bartlett Learning, LLC. Reference herein to any specific commercial product, process, or service by trade
name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or recommendation by
Jones & Bartlett Learning, LLC and such reference shall not be used for advertising or product endorsement pur-
poses. All trademarks displayed are the trademarks of the parties noted herein. Synergy for Clinical Excellence: The
AACN Synergy Model for Patient Care, Second Edition is an independent publication and has not been authorized,
sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product.
There may be images in this book that feature models; these models do not necessarily endorse, represent, or par-
ticipate in the activities represented in the images. Any screenshots in this product are for educational and instruc-
tive purposes only. Any individuals and scenarios featured in the case studies throughout this product may be real
or fictitious, but are used for instructional purposes only.
The authors, editor, and publisher have made every effort to provide accurate information. However, they are not responsi-
ble for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for
the use of the products and procedures described. Treatments and side effects described in this book may not be applicable
to all people; likewise, some people may require a dose or experience a side effect that is not described herein. Drugs and
medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA)
for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the
accepted standard in this field. When consideration is being given to use of any drug in the clinical setting, the health care
provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing pre-
scribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determin-
ing the appropriate usage for the product. This is especially important in the case of drugs that are new or seldom used.
Production Credits
VP, Executive Publisher: David D. Cella
Executive Editor: Amanda Martin
Acquisitions Editor: Teresa Reilly
Associate Editor: Danielle Bessette
Associate Production Editor: Juna Abrams
Marketing Communications Manager: Katie Hennessy
Composition: S4Carlisle Publishing Services
Cover Design: Kristin Parker
Rights & Media Specialist: Wes DeShano
Media Development Editor: Troy Liston
Cover Image: © Wichudapa/Shutterstock
Printing and Binding: Edwards Brothers Malloy
Cover Printing: Edwards Brothers Malloy
Library of Congress Cataloging-in-Publication Data
Names: Hardin, Sonya R., editor. | Kaplow, Roberta, editor.
Title: Synergy for clinical excellence : the AACN synergy model for patient care / editors, Sonya R. Hardin, Roberta
Kaplow.
Description: Second edition. | Burlington, MA: Jones & Bartlett Learning,
[2017] | Includes bibliographical references and index.
Identifiers: LCCN 2016013601 | ISBN 9781284106565 (pbk.)
Subjects: | MESH: Critical Care Nursing—standards | Models, Nursing |
Treatment Outcome | Nurse Practitioners | Certification
Classification: LCC RT120.I5 | NLM WY 154 | DDC 616.02/8—dc23 LC record available at
http://lccn.loc.gov/2016013601
6048
Printed in the United States of America
20 19 18 17 16 10 9 8 7 6 5 4 3 2 1
Dedication
This book is dedicated to Susan, Grace, Jessie, James, Bria, and Adam. We are
indeed grateful for your love, support, and encouragement during our time away
from home working on the production of this book.
iii
Contents
Preface................................................................................................................ xiii
Acknowledgments............................................................................................... xv
Contributors....................................................................................................... xvi
Section I Introduction..........................................................1
Chapter 1 Introduction.................................................................................3
Mary Frances D. Pate
Introduction.................................................................................. 3
Synergy and Me .......................................................................... 3
Development of the Synergy Model............................................ 4
Synergy Model Assumptions ...................................................... 6
Patient Needs and Characteristics ............................................... 6
Nurse Competencies and Characteristics..................................... 6
Certified Nursing Practice............................................................ 7
Synergy Beyond Acute and Critical Care ................................... 7
Conclusion.................................................................................... 9
References.................................................................................. 10
iv
Contents v
Sources of Vulnerability............................................................. 19
Definition.................................................................................... 21
Nursing Strategies...................................................................... 22
Application of the Case Study to the Synergy Model................ 23
Examples of Resource Availability Levels................................. 23
Conclusion.................................................................................. 23
References.................................................................................. 23
Chapter 4 Stability......................................................................................25
Roberta Kaplow
Introduction................................................................................ 25
Predicting Instability.................................................................. 26
Definition.................................................................................... 27
Application of the Case Study to the Synergy Model................ 28
Examples of Stability Levels in Practice.................................... 28
Conclusion.................................................................................. 29
References.................................................................................. 29
Chapter 5 Complexity.................................................................................31
Roberta Kaplow
Introduction................................................................................ 31
Sources of Complexity............................................................... 31
Definition.................................................................................... 33
Application of the Case Study to the Synergy Model................ 34
Examples of High Complexity Levels in Practice..................... 34
Conclusion.................................................................................. 34
References.................................................................................. 34
Chapter 6 Resource Availability ................................................................36
Roberta Kaplow
Introduction................................................................................ 36
Human Resources ...................................................................... 36
Type of Insurance....................................................................... 37
Definition.................................................................................... 38
Application of the Case Study to the Synergy Model................ 39
Examples of Resource Availability Levels................................. 39
Conclusion.................................................................................. 39
References.................................................................................. 39
Chapter 7 Participation in Care ................................................................42
Roberta Kaplow
Introduction................................................................................ 42
Levels of Participation in Care................................................... 43
Factors Impacting Participation in Care..................................... 44
Roles in Participation in Care.................................................... 45
Obstacles to Participation in Care.............................................. 45
Outcomes of Patient Participation in Care................................. 46
vi Contents
Definition.................................................................................... 46
Patient Strategies to Promote Participation in Care................... 46
Provider Strategies to Promote Participation in Care................. 47
Application of the Case Study to the Synergy Model................ 49
Examples of Participation in Care.............................................. 49
Conclusion.................................................................................. 49
References.................................................................................. 50
Chapter 8 Participation in Decision Making............................................52
Roberta Kaplow
Introduction................................................................................ 52
Definition.................................................................................... 53
Barriers to Participation in Decision Making............................. 53
Nursing Strategies...................................................................... 54
Application of the Case Study to the Synergy Model ............... 55
Examples of Participation in Decision-Making Levels.............. 55
Conclusion.................................................................................. 56
References.................................................................................. 56
Chapter 9 Predictability ............................................................................58
Roberta Kaplow
Introduction................................................................................ 58
Survival of Critical Illness.......................................................... 59
Incidence and Timing of Side Effects........................................ 59
Intensive Care Unit Scoring Systems......................................... 59
Definition.................................................................................... 60
Application of the Case Study to the Synergy Model................ 61
Examples of Predictability Levels.............................................. 61
Conclusion.................................................................................. 61
References.................................................................................. 62
Moral Agency............................................................................. 75
Advocacy and the Synergy Model............................................. 76
Application of the Case Study to the Synergy Model................ 78
Conclusion.................................................................................. 78
References ................................................................................. 78
Chapter 12 Caring Practices........................................................................80
Donna Roberson and Sonya R. Hardin
Introduction................................................................................ 80
Caring Practices......................................................................... 80
Caring Skills............................................................................... 81
Caring in Nursing....................................................................... 81
Competency for Evaluating Caring Practices............................ 82
Definition.................................................................................... 82
Translation into Practice............................................................. 83
Application of the Case Study to the Synergy Model................ 85
Conclusion.................................................................................. 85
References.................................................................................. 85
Chapter 13 Collaboration.............................................................................88
Donna Lake and Roberta Kaplow
Introduction................................................................................ 88
Definition.................................................................................... 89
Collaboration in the Intensive Care Unit.................................... 89
Elements of Effective Collaboration.......................................... 90
Barriers to Effective Collaboration............................................ 90
Opportunities for Multidisciplinary Collaboration
in the ICU................................................................................... 90
Quality Care Delivery................................................................ 91
Interprofessional Collaboration.................................................. 92
How Did We Get Here? Importance of Collaboration
in Nursing................................................................................... 93
Communication.......................................................................... 95
The Master’s Essentials.............................................................. 96
Effective Teams.......................................................................... 97
Team Tools................................................................................. 97
Conclusion.................................................................................. 97
Application of the Case Study to the Synergy Model................ 99
References.................................................................................. 99
Chapter 14 Systems Thinking....................................................................102
Sonya R. Hardin
Introduction.............................................................................. 102
Causal Loops............................................................................ 103
Archetypes................................................................................ 104
Systems Modeling.................................................................... 104
Definition.................................................................................. 105
viii Contents
This book is a tribute to all the acute and critical care nurses who serve patients
worldwide. It is based upon decades of work by the American Association of
Critical-Care Nurses (AACN) in the development of a conceptual framework
for nursing practice: The AACN Synergy Model. The purpose of this book is to
provide nurses with the clinical knowledge needed to apply the Synergy Model
in practice and to help prepare nurses for certification examinations offered by
AACN. Significant additions were made to this edition of the book. As the mod-
el’s use has grown exponentially in a number of arenas, chapters have been added
to demonstrate how the model is applicable in the non-intensive care setting. For
example, chapters on integration of the Synergy Model in the perioperative and
ambulatory settings have been added. This edition also has chapters that illustrate
application of the Model to the practice setting, nursing administration, research,
nursing orientation programs, and as a basis for a Doctor of Nursing Practice
project, creating a patient acuity system, and for obtaining Magnet® designation
by the American Nurses Credentialing Center. A chapter was written to tie the
Synergy Model to the APRN Consensus Model. This text can be utilized in a
nursing course that focuses on nursing theory and conceptual frameworks. The
chapters with practice questions have also been expanded in this edition of the
book. There are seven chapters with practice questions for certification examina-
tions to help prepare exam candidates.
Chapter 1 presents a brief history of the development of the model and
the patient and nurse characteristics inherent in the Synergy Model. The first
chapter in Section I serves as a foundation for understanding the application
of the concepts in each of the chapters that follow. Section II provides in-depth
chapters focusing on each patient characteristic in the model with application
to patient situations to further explicate the use of the model in practice. Sec-
tion III consists of chapters focused on the nurse characteristics with applica-
tions to practice. Section IV consists of chapters that illustrate how the Synergy
Model has been utilized in a variety of clinical and non-clinical settings. Sec-
tion V has sample test questions for those nurses seeking to obtain certification
through AACN or the American Association of Nurse Executives. These ques-
tions provide the nurse with further examples of the integration of the model
into practice.
xiii
xiv Preface
We would like to thank the contributors to the second edition of this book.
This book has been edited to enhance the readers’ understanding of the Synergy
Model. It should also provide a reference to those who are in the process of utiliz-
ing the model in their practice and those considering having a theoretical basis for
their practice.
Sonya R. Hardin
Roberta Kaplow
Acknowledgments
xv
Contributors
Marianne Baird, MN, RN, ACNS-BC Christine Estabrook, DNP, MSN,
Corporate Director, Magnet Recognition ANP-BC, AOCNP
Program Assistant Professor
Emory Healthcare University of South Alabama
Atlanta, GA Mobile, AL
Jeffrey Boon, MSN, RN, AGACNP-BC Deena Gilland, MSN, RN, OCN,
Neurology/Neurosurgery ICU Nurse NEA-BC
Practitioner VP and CNO Ambulatory
Assistant in Anesthesiology, Division of Patient Care
Anesthesiology Critical Care Medicine Emory Healthcare
Vanderbilt University Medical Center Adjunct Instructor Nell Hodgson
Nashville, TN Woodruff School of Nursing
Atlanta, GA
Mary Bylone, MSM, RN, CNML
President, Leaders Within, LLC Randy M. Gordon, DNP, FNP-BC
Colchester, CT Assistant Professor
Chamberlain College of Nursing
Kim Cooley, MSN, APRN, NNP-BC, Chicago, IL
CCNS
Neonatal Clinical Nurse Specialist Sonya R. Hardin, PhD, NP-C, RN,
Emory University Hospital Midtown CCRN
Atlanta, GA Professor
East Carolina University College
Robin Webb Corbett, PhD, FNP-C, of Nursing
RNC Greenville, NC
Department Chair, Department of
Advanced Practice and Education Carol Hartigan, MA, RN
East Carolina University College of Certification and Policy
Nursing Strategist
Greenville, NC American Association of Critical-Care
Nurses
Kristin Curcio, DNP, AGPCNP-BC, AACN Certification Corporation
AOCNP Aliso Viejo, CA
Clinical Assistant Professor
Community Practice Nursing Carolyn Horne, PhD, RN, BC
University of North Carolina, Greensboro Director, Clinical Nurse Specialist
Greensboro, NC Concentration
Assistant Professor
Becky Dean, MSN, APRN, ACNS-BC, Graduate Department
CCRN East Carolina University College
Clinical Nurse Specialist of Nursing
Emory University Hospital Greenville, NC
Atlanta, GA
xvi
Contributors xvii
Introduction
C h a p t e r 1
Introduction
Mary Frances D. Pate
INTRODUCTION
The AACN Synergy Model for Patient Care was developed in the 1990s as a
framework for certification. Since its inception, its utilization has grown in a num-
ber of areas. For example, the model serves as a foundation for other certification
exams, undergraduate and graduate nursing programs, and as a professional prac-
tice model in the hospital setting. In addition, the model has been used to guide
DNP projects and PhD dissertations. This chapter describes the development of
the model and its evolving role in nursing.
SYNERGY AND ME
My first interaction with nursing theories, conceptual frameworks, and models
occurred during undergraduate nursing school and reared its ugly head again
when I entered my master’s education. During this latter time, I was encouraged
(coerced) to select a model to serve as the basis for my advanced nursing practice.
Don’t get me wrong; a foundation for one’s nursing practice is essential, but from
my perspective at the time, I was at a loss for finding anything that was a fit for
practice in the “real world” of acute and critical care nursing. I completed the
requirements for my master’s degree by selecting a random nursing theory and
force fitting it to my practice to meet the requirements for graduation. I completed
my doctoral education by using a nonnursing theory for my doctoral dissertation,
about which I was fully questioned by the dean during my doctoral defense.
Years passed, and I learned of The Synergy Model for Patient Care through my
membership with the American Association of Critical-Care Nurses (AACN). When
I was introduced to the model, it made perfect sense, as it reflected the lived reality
that I had experienced as a critical care nurse. It was as if the stars aligned, the sun
shone through, and all became right with the world. I had finally found my model for
nursing practice, and through conversations with acute and critical care nurses over
the years, others seemed to sense the same fit with actual nursing practice.
3
4 Chapter 1 Introduction
The Synergy Model now serves as the organizing framework for AACN’s
CCRN®, PCCN®, ACNP-AG®, and AACNS-AG® certification exams. Renewal
by Synergy Continuing Education Recognition Point (CERPs) for the CCRN and
PCCN exams allows certificants to demonstrate commitment to continuing compe-
tency in nursing practice by integrating the Synergy Model into the renewal process.
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.