AMERICAN JOURNAL OF CRITICAL CARE, January 1998, Volume 7, No. 1

Martha AQ Curley, RN, PhD, CCRN. From Children's Hospital, Boston, Mass. Past Chairman of the Board, American Association of Critical-Care Nurses Certification Corporation, Aliso Viejo, Calif

Given the current demands of the healthcare environment, a clear sense of the unique contributions of nursing to patients' outcomes is critical. This paper articulates a model that describes nursing practice on the basis of the needs and characteristics of patients. The model was developed by the American Association of Critical-Care Nurses Certification Corporation to link certified practice to patients' outcomes. The fundamental premise of this model, known as the Synergy Model, is that patients' characteristics drive nurses' competencies. When patients' characteristics and nurses' competencies match and synergize, outcomes for the patient are optimal. This paper presents the major tenets of the Synergy Model: patients' characteristics of concern to nurses, nurses' competencies important to patients, and patients' outcomes that result when patients' characteristics and nurses' competencies are mutually enhancing. By creating safe passage for patients, nurses make a significant contribution to the quality of patients' care, containment of costs, and patients' outcomes. Although the Synergy Model will be used as a blueprint for the certification of acute and critical care nurses, it is conceptually relevant to the entire profession. Dissemination of this model may help situate nursing within the current healthcare environment and facilitate intradisciplinary dialogue. (American Journal of Critical Care. 1998;7.64-72)

Currently, the practice of inpatient nursing is in flux. Lower nurse-to-patient ratios, increased use of unlicensed assistive personnel, and shorter lengths of hospitalization, layered on a cumbersome healthcare system, challenge nurses' ability to provide adequate care as traditionally defined for patients. Given nursing's history of advocacy for patients, these are indeed difficult and frustrating times. Acknowledgment of the primacy of care based on the needs of patients may help the profession transcend and evolve from this unsettling period. Of critical importance is the articulation of nurses' unique contribution to patients' outcomes, that is, articulating the "value added" by nursing in the provision of healthcare services.

In an effort to link certified practice to patients' outcomes in the acute care setting, the American Association of Critical-Care Nurses (AACN) Certification Corporation designed a model that describes nursing practice based on the needs and characteristics of patients and the demands of the healthcare environment predicted for the future. The fundamental premise of this model, known as the Synergy Model, is that patients' characteristics drive nurses' competencies. When patients' characteristics and nurses' competencies match and synergize, patients' outcomes may be optimized.

Synergy is an evolving phenomenon that occurs when individuals work together in mutually enhancing ways toward a common goal. The Synergy Model recognizes the combined actions of both the patient and the nurse. Within this model, the patient and the patient's family are active participants in the patient-nurse interaction. The interaction is reciprocating and co-constituting in that each person exists because of the other, that is, the patient needs nursing care and the nurse needs a patient or a patient's family to care for. Synergy derives from responsive interdependence, intersubjectivity, shared commonality, and equity within the patient-nurse relationship. Patient-nurse synergy results in a better outcome than that which could be achieved independently.

The purpose of this paper is to present the major tenets of the Synergy Model: characteristics of patients that are of concern to nursing, nurses' competencies that are important to patients, and patients' outcomes that result when patients' characteristics and nurses' competencies are mutually enhancing. Although the Synergy Model will be used as a blueprint for the certification of acute and critical care nurses, it is conceptually relevant to the entire profession. Dissemination of this model may help situate nursing within the current healthcare environment and facilitate intradisciplinary dialogue.

Patients' Characteristics

Contextually, each patient and family is unique with various capacities for health and vulnerability to illness. The socioecologic determinants of health are noted in Figure 1. Each individual possesses a singular genetic and biological makeup that establishes a capacity for health. Each individual practices various degrees of healthy behaviors, for example, diet, exercise, and stress reduction. Each lives within a community with different institutions, economic structures, government, social organization, and community perceptions. All exist within a macrosocial structure consisting of societal infrastructure, the physical environment, cultural characteristics, and population perceptions. All these factors place the patient within context of an individual, unique environment and affect the nursing care required for a particular patient and family.

Each person brings a unique cluster of personal characteristics to a healthcare situation. These characteristics-stability, complexity, predictability, resiliency, vulnerability, participation in decision making and care, and resource availability-span the continuum of health and illness. Stability refers to the person's ability to maintain a steady-state equilibrium. Complexity is the intricate entanglement of two or more systems (e.g., body, family, therapies). Predictability is a summative patient characteristic that allows the nurse to expect a certain trajectory of illness. Resiliency is the patient's capacity to return to a restorative level of functioning by using compensatory and coping mechanisms. Vulnerability refers to an individual's susceptibility to actual or potential stressors that may adversely affect outcomes. Participation in decision making and care is the extent to which the patient and the patient's family engage in decision-making and in aspects of care. Resource availability refers to resources the patient, the patient's family, and the community bring to a care situation; resources are personal, psychological, social, technical, and fiscal.

These seven continuums are applicable to patients in all practice settings. This is important for nurse-to-nurse communication of patients' characteristics across traditional unit and system boundaries. For example, a healthy, uninsured, 40year-old woman undergoing a pre-employment wellness screening could be described as an individual who is (a) stable, (b) not complex, (c) very predictable, (d) resilient, (e) not vulnerable, (f) able to participate in decision making and care, but (g) has inadequate resource availability. On the other hand, a critically ill infant with multisystem organ failure can be described as at the other end of the continuum in some areas but as very similar in others, for example, as an individual who is (a) unstable, (b) highly complex, (c) unpredictable, (d) highly resilient, (e) vulnerable, (f) unable to become involved in decision making and care, but (g) has adequate resource availability.

Individuals vacillate at different points along these seven continuums. For example, in the case of the critically ill infant with multisystem organ failure, stability can range from a high to low risk of death, complexity from atypical to typical, predictability from uncertain to certain, resiliency from minimal to strong reserves, vulnerability from susceptible to safe, family participation in decision making and care from no capacity to full capacity, and resource availability from minimal to extensive. At any point in time, various combinations of these seven continuums paint a different picture of the patient. From a clinical perspective, this makes sense. Patients' characteristics evolve over time; what might seem very important one day may be less important the next.

Nurses' Competencies

Nursing competencies, derived from the needs of patients, can also be described in terms of essential continuums: clinical judgment, advocacy and moral agency, caring practices, facilitation of learning, collaboration, systems thinking, diversity of responsiveness, and clinical inquiry. Clinical Judgment is clinical reasoning that includes clinical decision making, critical thinking, and a global grasp of the situation coupled with nursing skills acquired through a process of integrating formal and experiential knowledge. Advocacy and moral agency is defined as working on another's behalf and representing the concerns of the patient, the patient's family, and the community. The nurse serves as a moral agent when assuming a leadership role in determining and helping to resolve ethical and clinical concerns within the clinical setting. Caring practices are a constellation of nursing activities that are responsive to the uniqueness of the patient and the patient's family and create a compassionate and therapeutic environment with the aim of promoting comfort and preventing suffering. Caring behaviors include, but are not limited to, vigilance, engagement, and responsiveness. Facilitation of learning is the ability to use the self to facilitate patients' learning. Collaboration is working with others (patients, families, healthcare providers) in a way that promotes and encourages each person's contributions toward achieving optimal or realistic goals for the patient. Collaboration involves intradisciplinary and interdisciplinary work with colleagues. Systems thinking is appreciating the care environment from a perspective that recognizes the holistic interrelationships that exist within and across healthcare systems. Response to diversity is the sensitivity to recognize, appreciate, and incorporate differences into the provision of care. Differences may include, but are not limited to, individuality, cultural practices, spiritual beliefs, sex, race, ethnicity, disability, family configuration, lifestyle, socioeconomic status, age, values, and alternative care practices involving patients and their families and members of the healthcare team. Clinical inquiry is the ongoing process of questioning and evaluating practice, providing informed practice based on available data, and innovating through research and experiential learning. The nurse engages in clinical knowledge development to promote the best outcomes for patients.

All these competencies reflect a dynamic integration of knowledge, skills, experience, and attitudes needed to meet patients' needs and optimize patients' outcomes. Nurses become competent within each continuum at a level that best meets the fluctuating needs of their population of patients. Logically, more compromised patients have more severe or complex needs; this in turn requires the nurse to possess a higher level of knowledge and skill in an associated continuum. For example, if the gestalt of a patient were stable but unpredictable, minimally resilient, and vulnerable, primary competencies of the nurse would be centered on clinical judgment and caring practices (which includes vigilance). If the gestalt of a patient were vulnerable, unable to participate in decision making and care, and inadequate resource availability, the primary competencies of the nurse would focus on advocacy and moral agency, collaboration, and systems thinking. Although all eight competencies are essential for contemporary nursing practice, each assumes more or less importance depending on a patient's characteristics. Synergy results when a patient's needs and characteristics are matched with a nurse's competencies.

Aiken et al 2(p772) note that the current expectations for professional nursing practice are high: "Care has become increasingly complex; the exercise of professional judgment by nurses is ever more important in preventing adverse and sometimes catastrophic events." Clinical expertise, that is, skilled clinical knowledge, use of discretionary judgment, and the ability to integrate complex multisystem effects and understand the expected trajectory of illness and human response to illness, creates safe passage for patients. In fact, excellent nursing care is often invisible, and, from a perspective of preventing untoward effects and complications, it should be. Nursing's unique contribution to patients within the healthcare environment, the one that encompasses all nurses' competencies, is that nurses create safe passage for patients and patients' families. Safe passage may include helping the patient and family move toward greater self-awareness and self-understanding, competence, and health, and through transitions and stressful events and/or a peaceful death.

Safe passage requires that the nurse "know the patient." Tanner et al 3 described "knowing the patient" as a primary caring practice that includes knowing the patient as a person and having in-depth knowledge of that individual's typical responses. Knowing the patient refers to how a nurse understands a patient, grasps the meaning of a situation for a patient, or recognizes the need for a particular intervention. Knowing the patient requires clinical judgment and creates the possibility for advocacy that limits the patient's vulnerability.

Agency, an expression of responsibility for a patient's outcome, includes assessing the situation on the basis of changing relevance, including action based on significance inherent in the situation, and a practical grasp of other clinicians' perception of the situation.4 Moral agency is a competency that acknowledges the unique trust inherent within nurse-patient relationships, a trust gained from nurses' long history of speaking on the patient's behalf in an effort to preserve a patient's "lifeworld" (P Hooper, RN, PhD, CCRN, oral communication, 1996).

Caring practices that create a safe environment for patients include nursing competence, vigilance, presence, engagement, and responsiveness. As a basic value, caring embodies a spiritual and metaphysical dimension concerned with preserving, protecting, and enhancing human dignity and integrity.5,6 Caring practices include not only what nurses do but also how they do it. Caring practices optimize and make visible clinical judgment. Essential to the process of caring is the nurse's recognition and appreciation of the worth of the patient and the patient's family, competency to know and attend to self, and congruence of care with the needs perceived by the patient and the patient's family.7-10 Providing patients with the opportunity, accountability, and responsibility to make their needs explicit requires consumer education. Nurses facilitate learning by patients so that patients can understand the healthcare system and make informed choices.

Creating a safe environment includes managing complex systems. Jacques,11 an organization theorist who studied the structural dimensions of nurses' work, notes, "The nurse is the one person on the unit whose job is to care about anything that might happen in the universe of the patient and to connect any parties who need to be connected in order to assure a successful outcome for the patient." Similarly, Schumacher and Meleis12 gave evidence to support "transitions" as a central concept in nursing. Relationships between nurses and patients generally occur around transitional periods of instability brought on by the demands of developmental, situational, or health-illness changes. Facilitating transitions across traditional healthcare system boundaries, for example, into and out of the community, requires systems savvy and intradisciplinary collaboration.

Whereas nurses have learned to manipulate the system to work for patients, systems thinking,13 the ability to understand the interrelationships and patterns involved in complex problem-solving, is a new, but essential skill in ensuring that appropriate care is provided within today's market-driven healthcare environment. Multidisciplinary teams require coordination of diverse clinical responses to ensure integration of care. Nurses are comfortable as team leaders, team members, and colleagues while providing supervision of unlicensed employees. Delegation is a new activity for those with singular experience within a primary nursing model.

Last, clinical inquiry helps push the limits of current practice so that patients receive evidence-based care. Studying the clinical effectiveness of care and how it affects patients will provide information that will help determine where to draw the line between cost and quality. It seems reasonable to note that only care that benefits patients is worth providing.

Optimal Outcomes for Patients

According to the Synergy Model, when patients' characteristics and nurses' competencies match and synergize, patients' outcomes are optimized. Many outcome measures have been proposed, including physiological status, psychological outcomes, functional measures, behavior, knowledge, control of signs and symptoms, quality of life, home functioning, family strain, goal attainment, use of service, safety, problem resolution, patients' satisfaction, and caring.14 But, what specific optimal outcomes can patients and nurses expect when care is based on the Synergy Model?

Making acute care nursing visible by delineating nurse-sensitive outcomes is challenging. "Nurse-sensitive" outcomes, a term first coined by Johnson and McCloskey,15 define a dynamic patient or family caregiver state, condition, or perception that is responsive to nursing interventions. Outcomes are stated as concepts that can be measured along a continuum rather than as goals.16

Numerous mediating factors affect nurse-sensitive outcomes. First, optimal outcomes for patients require both the unique and collective contributions of the patient and the patient's family, the nurse, the entire multidisciplinary team, the healthcare system, and the community. According to Mitchell,17(p6) outcomes should be "relevant to the individual's goals in seeking care, the institution's social contract in providing care, and the society's value and understanding of elements relevant to public as well as private health." The Synergy Model views patients in the context of their environments and as active participants in the care process. Thus, the responsibility and accountability for optimal outcomes for patients is shared.

Isolating nursing from the unique contributions of the patient and the patient's family and other practitioners is problematic.18 Brooten and Naylor19(p98) note, "The current search for 'nurse-sensitive patient outcomes' should be tempered in the reality that nurses do not care for patients in isolation and patients do not exist in isolation." What might be influenced by nursing care in one context may be influenced by another discipline or family in another.

Fearing that changes in both the structure and composition of the nursing workforce would jeopardize patients' safety, the American Nurses Association" published Nursing Care Report Card for Acute Care Setting-s. The purpose of this report was to begin to explore the nature and strength of linkages between nursing care and patients' outcomes. From an initial pool of 21, 6 major nursing quality indicators were determined; they include satisfaction of the patient and the patient's family, rate of adverse incidents, complication rate, the patient's adherence to the discharge plan, mortality rate, and the patient's length of stay. Adverse incident rates include medication errors and patients' injuries not directly related to their primary healthcare problem. Total complication rates include additional healthcare problems, for example, pressure ulcers and nosocomial infections that are unrelated to the patient's primary healthcare problem.20 Both these factors alter safe passage and increase patient suffering, risk of mortality, length of stay, and healthcare spending.21,22

The Synergy Model is congruent with the Nursing Care Report Card for Acute Care Settings,20 and provides a framework for outcome analysis. Three levels of outcomes are delineated: those derived from the patient, those derived from the nurse, and those derived from the healthcare system (Figure 2). Keeping the patient in a primary position, "optimal patient outcomes" are what patients themselves (or the people of significance to the patient) define as important. Safe passage is reflected in a number of these outcome variables.

Outcomes Derived from the Patient

From the patient's perspective, illness is associated with perceived vulnerability and powerlessness that stimulates the need for both competence and caring that could inspire immediate and unqualified trust.23 In part, trust results from the nurse's knowing the patient and the patient's knowing the nurse. Trust is a product of the nurse's clinical competency and moral agency. Patients and families will be vigilant if they are concerned about caregiver competence, agency, or both.24 Fidelity to patients' concerns, family empowerment, and coaching honor the outcomes of moral agency.

Caregiver trust is a prerequisite for the dispensing and the receiving of information. Whereas knowledge itself is not an outcome, the associated change in patients' health behavior related to the knowledge is an outcome. Patients and their families have grown in their knowledge about health and its promotion and have gradually assumed a greater responsibility for their own health.25

From the patients' perspective, care that comforts them, especially when they are acutely ill, is one of the most basic services that caregivers can provide. Caring practices create a compassionate and therapeutic environment with the aim of promoting comfort and preventing unnecessary suffering. The patient's experience of comfort is a quality-of-care outcome.26

Patients' and their families' satisfaction and ratings are subjective measures of individual health and quality of health services. Whereas such satisfaction measures involve querying individuals about their expectations and the extent to which they were attained, ratings include individual assessment of fact, for example, level of overall health or time one waited for services. Measures of patients' satisfaction with nursing typically include technical-professional factors, trusting relationships, and education experiences.27

Patient-perceived functional change and quality of life are multidisciplinary outcome measures. Nurses uniquely help patients manage through transitions of functional health and quality of life. Both these generic outcome measures can be used across all populations of patients, but, when analyzed separately, provide information specific to a population of patients. Precise longitudinal measures, for example, use of the SF-36 scale of physical and mental health,28 are important so that real change in status can be detected over time. Measuring functional status at intermediate steps will map the trajectory of a patient's recovery. Linking patients' satisfaction, functional status, and quality of life is important, as the three are often related.

Outcomes Derived From the Nurse

Outcomes provided by the caregiver include physiological changes, the presence or absence of preventable complications, and the extent to which care and treatment objectives were attained. Monitoring and managing instantaneous therapies by noting trends in physiological changes is a specific phenomenon of acute care nursing.29 For example, when weaning a patient from mechanical ventilation, the nurse would expect to find a gradual transference of the work of breathing from the ventilator to the patient. When a nurse "knows" the patient, a certain trajectory of physiological changes, for example, arterial blood gases and the percentage of minute ventilation assumed by the patient, can be anticipated, monitored, and then evaluated.

Outcomes related to limiting iatrogenic injury and complications of therapy acknowledge the potential hazards inherent in illness and the healthcare environment. Again, through their vigilance and clinical judgment, nurses create healing environments that provide safe passage for vulnerable persons. Safe passage mandates preventive care, for example, the prevention of iatrogenic injury, infection, and hazards of immobility (eg, pressure ulcers).

The extent to which care and treatment objectives are attained within the predicted time period also serves as an outcome variable. Nurses coordinate the day-to-day efforts of the entire multidisciplinary team. The nurse's role as the integrator of numerous services is critical for optimal outcomes for patients and abbreviated lengths of stay. A high degree of collaboration and positive interaction between nurses and physicians is associated with lower mortality rates, high patient satisfaction regarding care, and low rates of nosocomial complications.30,31

Outcomes Derived from the System

To survive economically, healthcare systems must tighten resources and maintain quality, which is collaboratively defined by both users and providers in the system. The goal is high quality care at moderate cost for the greatest number of people.32 Outcome data provided by the system includes recidivism and costs and resource utilization.

Recidivism, that is, rehospitalization or readmission, is rework that adds to the personal and financial burden of providing care. In addition to factors concerning the patient and the system, nurses can decrease the patient's length of stay through coordination of care, prevention of complications, timely discharge planning, and appropriate referral to community resources. Reducing length of stay and tracking rehospitalization and acute care visits assure that cost shifting is not occurring.

Payers are not interested in spending more for similar clinical outcomes. They are also not interested in assessing the unique contributions of a specific discipline, but rather wish to assess the entire outcome from an episode of care. Clinical effectiveness questions are answered by linking patients' outcomes to cost data. Strong data serve as the safety net to protect against too little care. Benner notes that cost-effective care will exist only in situations in which the patient is known and continuity of care is provided by expert caregivers.33 Continuity in care and clinical judgment stabilize care within chaotic environments.

Measurement Issues

Outcomes data can be grouped in numerous ways, for example, at the individual, system, or population level; specific to a subspecialty of nursing or generic to nursing as a whole; specific to a condition or disease or generic to a body system; or by acute or chronic illness. When to determine patients' outcomes can also be problematic-should outcomes be measured at discharge or at some later time?

Initiating an outcomes measurement plan may appear overwhelming, but it is imperative that nurses at least start to collect data that informs nurses in practice as models of care delivery change. Two remarkable findings of the American Nurses Association's Nursing Care Report Card.for Acute Care Settings were the lack of data necessary to measure and track nursing quality indicators and the fact that many of the indicators were not specific to nursing. 20 Data collection should be efficient, effective, and affordable. To start, one might consider a modular approach by selecting at least one clinical, economic, and patient subjective measure. The outcome chosen should make sense for the population of patients, for example, functional status after hip replacement surgery, change in behavior in a diabetic population, or comfort in patients with end-stage cancer. If a full panel of outcome measures is desirable, random stratified sampling may help to make the project manageable. What is important is to track changes on a longitudinal basis. Longitudinal reporting in the form of report cards will help monitor the effect of system changes over time.

What Next?

Nurses can apply the Synergy Model to their own practice setting. Can nurses define their practice from the perspective of patients' needs? Can the seven characteristics of patients be recognized by nurses? Do the patients' characteristics accurately describe the full spectrum of patients cared for by nurses? Can the eight nurses' characteristics be recognized by nurses? Can clinical exemplars be used to vividly portray synergy between the patient and the nurse? Do patients experience optimal outcomes when patient-nurse synergy is present? These questions are currently being asked by the AACN Certification Corporation in a study of practice.

For the past 20 years, AACN Certification Corporation has credentialed critical care nurses by using a body systems framework. This framework is no longer relevant. Much of what nurses do that truly makes a difference for patients is not reflected in the current certification process. Certification programs that concern themselves with competencies that move patients toward specified outcomes in a measurable way will mean something to the patient, profession, employer, and society at large. Because the Synergy Model clearly articulates the essence of the patient-nurse relationship, it provides a blueprint to ensure the continued relevancy of certification programs in the future.

Also important is redesigning recertification processes so they acknowledge, reflect, and stimulate practitioner professional growth. Although current recertification processes do not accomplish this, if they did, they could help articulate the advantages of the presence of experienced nurses at the patient's bedside. Assuring continued competence of healthcare professionals is critical to consumer protection.34

Critical links exist between clinical practice, certification, nursing education, and research. As the practice has evolved, so must nursing education. Necessary course work must continue to expand to reflect the demands of the clinical environment. Systems management requires systems education-a much broader perspective than what is currently available in most baccalaureate programs. The Synergy Model articulates nursing competencies that are congruent with baccalaureate and graduate education, yet a significant proportion of the nursing workforce has less than baccalaureate preparation. The multiple educational pathways that have caused more than 30 years of debate must give way to an appreciation of what various levels of professional education can offer. In order for this to occur, the profession must more definitively differentiate the education patterns, practice, and salary of various levels of nurses.35

Clinical research is necessary to support the epistemological links and outcomes posited within the Synergy Model. Nursing's primary model for knowledge generation has been the empirical/analytic model of the traditional sciences.36 Holism, the core of nursing, stands in direct opposition to objectivism and its associated reductionism. 37 Numerous caring behaviors that create safe passage for patients, especially those behaviors mentored by peers, for example, clinical leadership, creating trust, comforting behaviors, and orchestrating death are best investigated by using qualitative methodologies. Yet, although qualitative methods more accurately describe the essence of nursing, they lack a causal, predictive requirement. This limits their use as a sole strategy of inquiry for designing what nursing should look like in the future. From a quantitative research perspective, Mitchell notes that lack of common databases for evaluating outcomes is the most salient indicator of our lack of system-level thinking in both policy and clinical arenas. Achieving outcome measures in the Nursing Minimal Data Set could advance quality measurement in nursing.38

This paper has presented the major tenets of the AACN Certification Corporation's Synergy Model. Although thinking continues to evolve, it is hoped that its current dissemination will help nurses focus on their unique contributions, initiate processes to either start or refine measurement of nurse-sensitive outcomes, and stimulate intradisciplinary dialogue. By continuing the historic tradition of creating safe passage for patients, nurses make a significant contribution to the quality of patients' care, containment of costs, and patients' outcomes.

ACKNOWLEDGMENTS

Members of the think tank who developed the conceptual framework include Martha AQ Curley, RN, PhD, CCRN, Mairead Hickey, RN, PhD, Pat Hooper, RN, PhD, CCRN, Bonnie Niebuhr, RN, MS, Wanda Roberts Johanson, RN,MN, Sarah Sanford, RN, MA, CNAA, and Gayle R Whitman, RN, MSN. Subject-matter experts who defined the continuums of patients' and nurses' characteristics include Martha AQ Curley, RN. PhD, CCRN, DuAnne Foster-Smith, RN, MN, CCRN, Deborah Gloskey, RN, MS, CCRN, Janet Fraser Hale, RN, CS, PhD, CCRN, Teresa Halloran, RN. MSN, CCRN, Pat Hooper, RN, PhD, CCRN, Sonya Hardin, RN. PhD, CCRN, Mairead Hickev, RN. PhD, Vicki Keough, RN, MSN, TNS, TNCC, Patricia Molonev-Harmon, RN, MS, CCRN, Kathleen Shurpin, RN, PhD, CS, ANP, OCN, and Daphne Stannard, RN, PhD, CCRN. Members of the outcomes think tank who articulated optimal outcomes for patients include Patricia Benner, RN, PhD, Melissa Biel, RN, MSN, Martha AQ Curley, RN, PhD, CCRN, Wanda Roberts Johanson, RN, MN, Marion Johnson, RN, PhD, Marguerite Kinnev, RN, DNSc, Benton Lutz, MDiv, EdS, Patricia Molonev-Harmon, RN, MS, CCRN, Alvin Tarlov, MD. and Cheri White, RN, MSN, CCRN.

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