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The role of clinical nurse specialists was formalized in the 1950s; the goal was to prepare inpatient, bedside nurses who would serve acutely ill patients via consultation and direct care. Clinical nurse specialists were to be expert clinicians, consultants, educators, and researchers. In the early stages of practice development, the focus was the specif ic needs of the assigned unit or floor. Organizational restructuring led to the elimination of many positions for clinical nurse specialists, with a shift of some of the nurses’ responsibilities to others (ie, managers) or the abandonment of some of the traditional roles. Recently, a reversal occurred in this trend, evidenced by a steady growth in the demand for these advanced practice nurses by organizations seeking to improve patients’ outcomes while remaining fiscally responsible. This demand led to changes in role expectations and expanded the responsibilities of clinical nurse specialists to a system-wide or organization-wide level. Contemporary practice of clinical nurse specialists is not well reflected in traditional role definitions or commonly accepted practice models. The Synergy Model, developed by the AACN Certification Corporation, was introduced as a way of linking certified practice to patients’ outcomes. The model describes 8 nurse characteristics and 3 spheres of influence. This article describes how a group of clinical nurse specialists applied the model to successfully change from a unit-based to a multisystem practice. (American Journal of Critical Care. 2002;11:436-446)
THE SYNERGY MODEL AND THE ROLE OF CLINICAL
NURSE SPECIALISTS IN A MULTIHOSPITAL SYSTEM
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By Sharon Saunderson Cohen, RN, MSN, CEN, CCRN, Nancy Crego, RN, MSN, CCRN, Richard G. Cuming, RN, MSN, CNOR, and Melinda Smyth, RN, MSN, CCRN, CNA. From North Broward Hospital District, Fort Lauderdale, Fla.
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he role of the clinical nurse specialist (CNS) was formalized in the 1950s; the goal was to prepare inpatient, bedside nurses who would serve acutely ill patients via consultation and direct care. A CNS was considered an expert clinician.^1 The defining roles were expert clinician, consultant, edu- cator, and researcher. 2 In the early stages of CNS practice development, the main focus was the specific needs of the assigned unit or floor. This focus was reflected by the limited nature of the 4 traditional defining roles. However, the current healthcare cli- mate has reshaped the roles of nurses at all levels, including the role of CNSs.
In many organizations, positions for CNSs were eliminated, with a shift of some responsibilities of these nurses to others (ie, nurse managers) or an abandonment of some of the traditional roles (ie, researcher, educator). Recently, a reversal occurred in this trend, evidenced by a steady growth in the demand for these advanced practice nurses by organi- zations seeking to improve patients’ outcomes while remaining fiscally responsible. Additionally, the trend of hiring and training recent nursing graduates in spe- cialty areas typically reserved for more experienced practitioners (eg, intensive care unit, operating room) has created a need for intense education and orienta- tion coordinated by CNSs. These organizational changes have led to modifi- cations in the role of CNSs and have expanded the responsibilities of these nurses to a system-wide or
organization-wide level. Nowadays, a CNS is expected to move through multiple units at a single location or various locations, facilitate process changes at a sys- tem-wide level, and expand his or her knowledge of specific patients cared for or services offered within the assigned areas. In addition, healthcare organiza- tions and regulatory agencies (eg, the Joint Commission on Accreditation of Healthcare Organizations) increasingly are demanding measur- able positive patient outcomes associated with changes in practice that are often CNS driven. Contemporary CNS practice is not well reflected in traditional role definitions or commonly accepted practice models. The Synergy Model, developed by the AACN Certification Corporation, was introduced as a way of linking certified practice to patients’ outcomes. 3 The model describes nurses’ practice on the basis of “the needs and characteristics of patients and the demands of the healthcare environment predicted for the future.” 2 Patients’ characteristics drive the nurses’ competencies, and when the characteristics of a patient and the competencies of a nurse match and synergize, patients’ outcomes are optimized.^3 The Synergy Model describes 8 characteristics of nurses (clinical judg- ment, clinical inquiry, facilitator of learning, collabo- ration, systems thinking, advocacy/moral agency, caring practices, and response to diversity) and 3 spheres of influence (patient/family, nurse-nurse, and system). 4 The North Broward Hospital District, Fort Lauderdale, Fla, is a multihospital system in an urban environment. The system, which is the seventh largest not-for-profit healthcare corporation in the United States, consists of 2 trauma centers (744 beds and 409 beds), 2 smaller community hospitals (204 beds and 200 beds), a freestanding ambulatory surgical center, an extensive array of ambulatory centers, and multiple physician-owned practices. The role of CNSs in the system was established by the administrator for patient care services at the largest hospital in the sys- tem. She had worked as a CNS in another state and recognized the potential benefit of this advanced prac- tice role in the Florida organization. The nursing spe- cialty areas are represented in our group by a total of 14 CNSs, who are responsible for medical-surgical nursing (4), women and children’s services (4), oncol- ogy nursing (1), critical care (2), trauma care (1), peri- operative services (1), and emergency services (1). For many years, the traditional unit-based role was followed in our system. However, when the system was restructured, the traditional unit-based CNS role was expanded to a multicenter model. In this article,
we describe how the Synergy Model was used to suc- cessfully develop the new CNS role and how this model assisted a group of CNSs in determining how to best serve the needs of an organization while con- tinuing to generate positive patients’ outcomes and maintain fiscal responsibility.
Clinical Inquiry
With the rapid advances in healthcare knowledge, clinical inquiry is more important than ever before. How can a group of CNSs working in a multicenter system foster enthusiasm for clinical inquiry? In gen- eral, clinical inquiry in the form of research has attained a rather “bad name” among bedside nurses. Many nurses have suffered through dry research courses in undergraduate and graduate programs, an experience that decreased their passion for further studies after graduation. Our CNS group thinks that creating an environment in which the pursuit of excel- lence supports clinical inquiry to improve clinical out- comes^4 is important in all hospitals within our system. To foster enthusiasm for research, we used multi- ple methods. Each CNS read and critiqued a nursing research article and then posted both the article and the critique in areas (eg, staff bathrooms) where staff members would have a few minutes of uninterrupted time to read the material. Staff members commented on some of the research topics posted and discussed some of the related issues with each other and with members of the CNS group. Research critiques writ- ten by the CNS group were also published in our dis- trict-wide nursing newsletter along with brief articles on research concepts (eg, developing research ideas, applying research at the bedside). These strategies increased understanding of research terminology and interest in research reviews. Simultaneously, CNSs participated in the devel- opment of a clinical ladder with a research compo- nent, a development that spurred an increased interest in research activities by staff nurses. However, many staff nurses expressed an inability to meet the research requirements of the ladder and requested assistance from the nursing research committee. Once the inter- est in clinical nursing research was enhanced, the CNS group developed a user-friendly tool to facilitate the ability of staff members to independently critique arti- cles (see Table). Additionally, CNSs promoted evi- dence-based practice by presenting formal seminars and by encouraging staff members to attend at least 1 meeting of the nursing research committee. Unlike many other facilities, our hospital system has an active nursing research committee, one that has existed for 12 years. The members of the committee
Research Evaluation Checklist (Continued)
Criteria Definitions Content Comments
Subjects
- Subject population is described*
- Sampling method is described*
- Statement that sampling method is justified through power analysis
- Inclusion/exclusion criteria are identified*
Instruments
- Type of instrument used is described (eg, questionnaire, Likert scale)
- Reliability of instrument is described*
- Validity of instrument is described*
Data Analysis
- Statistical tests used are identified, and obtained values are reported*
- Reported statistics are appropriate for type of question asked - Confounding/extraneous variables: Factors that interfere with obtaining a clear understanding of what is happening in a study
Sampling: Who will be in the study
- Random: Everyone in the population being studied has an equal chance of being chosen
- Convenience: Researcher includes individuals willing to participate; use of this type of sampling represents bias and limits generalizability of results n: Symbol for a sample size; number of participants/items being studied is important; small samples may not reveal differences among groups when differences are present and would have been detected in larger groups Power analysis: Means of establishing that a study was conducted on a large enough sample to justify results
Reliability: Ability of an instrument to consistently provide accurate results; reliability is expressed as a decimal value and can never be perfect Validity: Ability of an instrument to measure what it purports to measure (eg, stress). Four types may be mentioned:
- Construct: Most important type of validity; estimate of how well an instrument measures a theoretical construct (eg, creativity)
- Predictive: Ability of a tool to predict a phenomenon such as disease risk (eg, breast cancer)
- Content: Ability of a tool to measure the intended content area; may be described as “face” validity, meaning it appears valid, or “expert,” meaning experts in the field have examined it and think it is valid
- Concurrent: The extent to which a new instrument measures the same as an established instrument
Statistics: Mathematical tools that allow investigators to determine the likelihood that a result would occur because of chance (luck)
- Descriptive: Describe or summarize data, such as mean (average), mode, median, and standard deviation (eg, demographic data)
- Inferential: Used to make inferences from a sample to a larger population (eg, t tests, analysis of variance [ANOVA], and χ^2 ); shows how significant the differences are between groups
- Correlation: Shows whether or not and to what extent a relationship exists between variables; correlations do not prove causation
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review nursing research proposals, discuss plans to promote research in and around the organization, pro- mote evidence-based practice, plan educational expe- riences, and assist staff in learning how to meet the research component of the clinical ladder application. To facilitate attendance by clinical staff nurses, the cochairpersons (2 CNSs) changed the frequency of the meetings of the committee from quarterly to bimonthly; began rotating the location of the meeting to each of the hospitals in the system; and advertised the meeting schedule via unit-based flyers, nursing newsletters, and our Intranet. Because staff nurses
have limited meeting time at work, and as an incentive for attendance, lunch is provided at the meetings. With these changes, attendance increased from 8 to 30 staff nurses at meetings. Each meeting includes a 30-minute presentation on a research topic of interest (eg, institutional review boards, conducting literature searches, components of a research proposal), reviews of research proposals, and reviews of evidence-based practice standards (eg, blood conservation protocol, oral care procedure for intubated patients). Members of the nursing staff par- ticipate in nursing research by assisting with research
Research Evaluation Checklist (Continued) Criteria Definitions Content Comments
Discussion
- Conclusions are clearly stated*
- Conclusions are substantiated by evidence presented*
- Problems with method of the study are identified and discussed
- Limitations of the study are identified*
- Implications of the findings are discussed*
- Results are generalized only to the population on which the study is based
- Recommendations for further research are made
Miscellaneous Points
- Did the article come from a peer-reviewed journal?*
- Who funded the research study (eg, grant, foundation, pharmaceutical company)?
- Were the rights of the participants protected, and were confidentiality and anonymity maintained?
- Is the bibliography up to date?
Statistical significance: Term meaning the likelihood the study results would have occurred by luck or chance; expressed as a P value (eg, P = .05 means that in only 5 of 100 times, results would have been obtained by chance); smaller P values mean a smaller chance that results would have been obtained simply by chance (eg, P = .001 means that in only 1 of 100 times would results have occurred by chance; this value is usually the greatest level of significance in research)
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was provided to all staff on the surgical services (pre- operative, operating room, postanesthesia care, and anesthesia personnel). A multidisciplinary team, chaired by the CNS, was convened to develop a proto- col to prevent inadvertent perioperative hypothermia. Results have been encouraging. Before implementa- tion of the protocol, the prevalence of postoperative hypothermia was 25%. Six months after implementa- tion, the number of patients who became hypothermic had decreased by 12%.
Facilitator of Learning
As educational needs are recognized, the CNS group determines if the needs are related to a specific unit or are more global, spanning the hospital or sev- eral hospitals in our system. Some educational needs are best handled on a small scale, such as an individual care unit, whereas others require a larger forum such as a seminar. Nursing grand rounds are another mechanism for providing information and education. Each of the 4 medical centers sponsors this monthly event in which members of the nursing staff are responsible for planning and presenting an interesting case. During the presentation, staff members review cur- rent literature pertinent to the care of the patient whose case they are presenting and the patient’s his- tory, assessment, interventions, plan, and outcome. CNSs often facilitate use of resources for the litera- ture search and assist in developing audiovisual aids; however, staff members are responsible for presenting the case. By highlighting a specific patient and the patient’s family, professional staff are able to address the holis- tic and personal aspects of the staff ’s nursing care. Nursing grand rounds allow individual departments to showcase what staff members do best: care for people. Furthermore, in preparing for their talk and as a by- product of the review of current literature, staff mem- bers have the opportunity to ensure that nursing care is congruent with best practices. One example in which the literature search led to improvement in nursing care was the presentation of a case study of a law enforcement officer admit- ted to our trauma resuscitation unit who had blunt thoracic trauma that caused a pseudoaneurysm of the descending thoracic aorta. While researching the literature related to pseudoaneurysm, staff members discovered that a systolic blood pressure higher than 90 mm Hg is associated with increased mortality. 8 As a result of the literature search and case review, staff now provide improved care to patients with pseudoaneurysm.
Because of the varied skills and talents of the CNS group, a wealth of programs are available to facilitate learning within our multihospital system. Training courses are offered for many nursing special- ties, including emergency care, critical care, maternal- child health, perioperative nursing, trauma care, and oncology nursing. These formal training courses are ongoing and are scheduled in response to vacancy rates in the different clinical areas. Staff members always have an opportunity for professional growth. With 4 hospitals, a surgicenter, and several ambulato- ry centers to choose from, there is seldom a chance that a staff nurse would become stagnant in one area of nursing for lack of clinical challenge.
Clinical Judgment
In collaboration with the nursing staff, respiratory therapy personnel, medical staff, epidemiology staff, nutritional services staff, physical therapy personnel, and case management staff, the CNS group partici- pates in multidisciplinary rounds on selected groups of patients with complex conditions. Trauma rounds are done weekly to review the progress of all in-house trauma patients from resuscitation through rehabilita- tion. On ventilator weaning rounds, the care of patients receiving mechanical ventilation who require complex weaning strategies is reviewed. Discharge rounds are done for in-house patients with complicated discharge planning needs. By participating in rounds, CNSs support the nurs- ing staff ’s clinical judgment and act as mentors by sharing knowledge and experience in the care of patients with complex conditions. Specifically, the care plans of individual patients may be discussed and mod- ified on the basis of the patients’ responses to nursing intervention. The CNSs provide expertise encompass- ing research, critical thinking, collaboration, resource acquisition, education, and review of the plan of care. Recently, both the critical care CNS and the trauma CNS participated in rounds on a critically injured adult trauma patient. Injuries included massive pul- monary contusions and smoke inhalation. The patient was in acute respiratory distress with ventilation- perfusion mismatching. Traditional methods to reduce the mismatch were unsuccessful. The two CNSs pro- posed prone positioning as a treatment option for the patient’s injury. Collaboration was required between medicine, nursing, and respiratory therapy staff to implement the plan of care and determine an outcome measurement that would validate the success of treat- ment. Concomitant injuries prevented routine prone positioning of the patient, and staff asked for guidance in solving the logistics and understanding the physio-
logical endpoints to be measured. Turning to the liter- ature, the CNSs in collaboration with respiratory ther- apy and medical staff determined that the recommended outcome measure was the alveolar-arterial difference in oxygen. In addition, the CNSs supported staff nurses by developing a time schedule and came in to assist the nurses with placing the patient in the prone position. Individual CNSs also make frequent patient care rounds in clinical areas or may be consulted on spe- cific patient care needs. The presence of a CNS often triggers questions from staff related to nursing pro- cess or skills needed in the care of a specific patient. The presence of a clinical expert, who is not in a management capacity, encourages open discussion and curiosity by professional staff related to evi- dence-based practice and new trends in patients’ care.
Collaboration
Although the CNS group is divided by service responsibilities (eg, surgery, trauma, critical care, medical-surgical, oncology), we are successful in ini- tiatives involving large units, multiple departments, entire medical centers, or the hospital system only in so far as we are able to collaborate. Collaboration, the ability to work with others to achieve a common goal, is essential for advanced practice nurses to bring change or improvements to complex systems. 9 The old adage that “no man is an island” suits our experi- ences well. Furthermore, collaboration crosses the boundaries of most components of the Synergy Model, most notably, clinical judgment, facilitator of learning, sys- tems thinking, and caring practices. In other words, collaboration supports and enhances everything that we do. The critical care CNS facilitated a multidisci- plinary task force composed of physicians, anesthesi- ologists, and respiratory and pharmacy personnel to resolve problems regarding the lack of available medi- cations during emergency airway management proce- dures. The lack of neuromuscular blocking agents, controlled medications, and specialized airway devices on the resuscitation cart was identified as the cause of delays in definitive emergency airway man- agement at resuscitation events. Obstacles including refrigeration of medications, regulatory standards, and the expense of needed equipment prevented easy reso- lution of these issues. Having a collaborative physi- cian-CNS relationship allowed all parties to state their needs and resolve the problem. Our unifying goal is to improve the practice of clinical nursing within our system, thereby enhancing positive outcomes for patients and the experience of
our clients. Collaboration involves both intragroup and intergroup systems. We often work with healthcare providers from other disciplines (eg, physicians, phar- macists, dietitians) to meet our shared goals that include planning, implementing, and evaluating programs. CNS collaboration often leads to multiple con- ferences, seminars, and nurse internships planned and executed by the entire CNS group or by a select subset based on the expertise of the individual CNS. Conference topics are selected on the basis of staff needs assessments, clinical issues identified during rounds, literature review, best practices used outside our hospital district, risk management, and perfor- mance improvement trends. Some examples of this collaboration are forensics seminars conducted jointly by the trauma CNS and the perioperative CNS; a seminar on bedside emergencies developed collabora- tively by medical-surgical CNSs with lectures provid- ed by the emergency department CNS, the trauma CNS, and the critical care CNS; labor and delivery nurse internship programs with the surgical compo- nent taught by the perioperative CNS; and critical care nurse internship programs taught by many mem- bers of the CNS group. In response to new requirements of the Joint Commission on Accreditation of Healthcare Organizations for pain management, a collaborative multidisciplinary team was formed that included sev- eral CNSs. This collaboration has been an ongoing project involving research (eg, surveys, quality assur- ance), education (eg, lectures, subject matter experts), practice reviews, and practice changes (eg, assessment and response modifications to patients’ subjective experiences). In a large, multicenter system such as ours, it is important that lines of communication between indi- vidual CNSs remain fluid. Often weeks pass without seeing certain members of the group. As a group, we meet monthly to network, solve problems, generate ideas, ensure that projects remain on target, and sup- port one another. An annual strategic planning session is held off site to coordinate projects and educational offerings and avoid duplication of CNS effort. Additionally, the role of advanced practice nurses is one that is often poorly understood by the healthcare community and is difficult to justify. During strategic planning sessions, the CNS group, through collabora- tion with administration and other healthcare profes- sionals, is able to effect change within the system, thereby meeting our goals of improving the practice of clinical nursing, enhancing positive outcomes for patients and the experience of our clients, and show- ing that the role of CNSs is valuable.
Once the consultations were completed, the CNS arranged a conference that included Mr F.’s family and the primary members of the healthcare team. The ethics team agreed that cessation of mechanical ventilation was a morally sound decision and that maintaining ventilatory support violated Mr F.’s human right to self-determination. The legal team determined that withdrawing life support in this instance was congruent with the parameters of the Patient Self-Determination Act. Additionally, we were cautioned that to ignore Mr F.’s expressed wishes could be considered battery. Last, the independent psychiatrists determined that Mr F. was competent. With Mr F.’s family and the healthcare team, the CNS planned withdrawal from mechanical ventilation. A principal goal of the team was to preserve human dignity during the withdrawal. A detailed, written care plan was developed that addressed weaning, pain management, anxiety, and support of Mr F.’s family. Mr F. and his family were encouraged to spend time together and to inform the team when they were ready to proceed. The CNS acted as an advocate for Mr F. by sup- porting his right to self-determination while assisting with the resolution of the moral dilemma that with- drawal from mechanical ventilation represented for some members of the healthcare team. While caring for Mr F., the CNS demonstrated advanced practice skills of critical thinking while advocating for both Mr F. and members of the healthcare team. The CNS modeled holistic practice while considering the 3 spheres of influence within the synergy model: patient/family, nurse-nurse, and system (potential legal implications to the organization). 4 Despite the divergent perspec- tives of Mr F.’s case, the CNS guided the healthcare team so that the focus remained on the compassionate and professional care of Mr F. and his family. Mentoring of staff was evident throughout the care of Mr F. and his family. The healthcare team was mentored by the CNS in developing and implementing Mr F.’s plan of care, supporting and coping with family dynamics, and identifying and addressing legal and ethical principles. Synergy was achieved as the com- petencies of the healthcare team were modified to meet the needs and characteristics of Mr. F. and his family, optimizing the clinical outcome.^4
Response to Diversity
The diversity of the population of patients served by our hospital system may pose a challenge to some persons. Because we are in one of the most popular vacation destinations in the United States, we have a continual influx of tourists and of persons
relocating to the area. The mild winters, warm sum- mers, and year-round ocean and outdoor access attract a diverse group. The members of each popu- lation demand unique ethnic, cultural, religious, and healthcare considerations to meet their needs. The populations include old and very old persons, immi- grants from the Caribbean Islands, Canadians, South Americans, and Asian and Pacific Islanders. South Florida also has a large gay and lesbian population with unique healthcare needs and considerations. To some, this diversity may appear to be overwhelming, but members of our CNS group represent several of these cultures, lifestyles, and ethnic backgrounds. We view this diversity not as challenging but rather as rewarding and normal throughout our day-to-day responsibilities. Synergy is demonstrated through many of the system-wide processes implemented within our hos- pital system. For example, our pain management committee recognized cultural, ethnic, and age diversity as a critical aspect in the development of pain-rating tools. Our pain-rating tools are printed in three languages—English, Spanish, and Creole— and in extralarge type for patients with sight impair- ments. In order to accommodate preverbal children, neonates, and nonverbal adults, various reliable and valid tools to assess these special populations are available. For the treatment of patients with pain, allopathic and complementary modalities are incor- porated into policies and procedures implemented system-wide. All members of the healthcare team— medical, nursing, and allied health—are educated in the use of the pain-rating tools. Emphasis on cultural sensitivity and the importance of assessing the needs of each patient and his or her family were empha- sized during educational sessions.
Conclusion
Our CNS group has found that the Synergy Model can be used to accurately describe the transi- tion from the traditional unit-based practice of CNSs to a contemporary multisystem practice.^11 The key to our success has been the ability to communicate and collaborate with each other to influence the practice of each CNS, with better outcomes for patients and changes across the system.
ACKNOWLEDGMENTS All work was performed within the North Broward Hospital District.
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