The Synergy Model: Contemporary Practice of the Clinical Nurse Specialist

Critical Care Nurse, Vol 19, No 2, April 1999

Patricia A. Moloney-Harmon, RN, MS, CCRN

The Synergy Model, which serves as the framework for the CCRN exam, describes a patient-nurse relationship that optimizes patient and family outcomes.1 While much of the discussion about the Synergy Model has centered around individual patients and nurses, it can also be used to illuminate the role of advanced practice nurses, specifically, the contemporary practice of the clinical nurse specialist (CNS). While many may think the CNS role is extinct, in reality the "new" CNS is flourishing, a fact borne out by a review of the classified ads. This article reviews how the Synergy Model gives voice to the contemporary practice of the clinical nurse specialist.

Historically, CNS practice has been described as expert clinician, consultant, educator, and researcher. Individual differences aside, these 4 dimensions do not reflect contemporary advanced practice nursing. CNSs intervene on an individual patient/family level, a nurse-nurse level, and a systems level. Because the CNS's spheres of influence has evolved, so too must our conceptualization of its role dimensions. CNS practice can better be articulated by the Synergy Model's 8 nurse dimensions (Table 1). In fact, the Synergy Model will serve as the framework for the new CCNS exam as it describes CNS - patient/nurse/system relationships that optimize patient/family, nurse and system outcomes. How do the 8 nurse characteristics apply to the 3 spheres of influence in CNS practice?

Table 1 Clinical nurse specialist interventions in the three spheres of influence
Nurse dimension
Clinical judgment
Synthesize, interpret, and make decisions based on complex, sometimes conflicting, sources of data
Facilitate development of clinical judgment in healthcare team members (eg, nursing staff, medical staff, other healthcare providers) through role modeling, teaching, coaching, and/or mentoring
Develop, implement, and evaluate research-based algorithms, decision trees, protocols, and care plans for patients and patient populations
Clinical inquiry
Using research-based evidence/outcome data, formulate, evaluate, and/or revise policies, procedures, protocols, individualized patient care programs, and standards for care
Role model, teach, coach, and/or mentor nursing staff regarding the use and evaluation of research findings
Drawing on resources including the literature, benchmarking studies, and colleagues, design and evaluate innovations in clinical practice affecting patients/populations and/or systems
Facilitator of learning
Collaborate with patient/family, nursing staff, medical staff, and other healthcare professionals to develop, implement, and evaluate education programs based on learner needs
Facilitate nursing staff development of patient education-related skills (eg, needs assessment, evaluation of learner understanding, integrating education throughout delivery of care)
Contribute to and advance the knowledge base of the healthcare community through presentations, publications, and involvement in professional organizations
Lead or participate in multidisciplinary teams to develop programs based on patient care issues
Role model, teach, coach, and/or mentor professional leadership and accountability for nursing's role within the healthcare team
Involve/recruit diverse resources to optimize patient outcomes
Systems thinking
Develop, integrate, apply, and evaluate a variety of strategies that are driven by the needs and strengths of the patient/family, nursing staff, medical staff, and other healthcare professionals
Role model, teach, coach, and/or mentor creative/innovative systems thinking and resource use among nursing staff
Integrate knowledge or organizational mission, goals, and systems into patient care strategy, development, and implementation. Anticipate possible consequences of systems change, and develop proactive strategies.
Advocacy/moral agency
Establish an environment that promotes ethical decision making and patient advocacy
Facilitate development of nurse's advocacy and moral agency through role modeling, teaching, coaching, and mentoring
Develop community education programs in regard to such issues as living wills, advance directives, power of attorney, and organ donation
Caring practices
Develop and/or implement a process to ensure that patient/family needs are met in regard to body image, loss, healing, death, and dying/powerlessness
Facilitate development of nurses' caring practices through role modeling, teaching, coaching and/or mentoring
Provide patient/family skills to navigate transitions along the healthcare continuum (ie, facilitate safe passage)
Response to diversity
Recognize and integrate individual differences and complementary therapies into patient/family care
Identify issues arising from individual differences and develop awareness of these issues in nursing staff, medical staff, and other healthcare providers
Tailor the delivery of care, to the extent possible, to meet the diverse needs and strengths of patient/family, staff, and system
Adapted from the CCNS development committee, AACN Certification Corporation, 1998

Clinical judgment is shown by the CNS providing clinical expertise, in addition to planning, effectively implementing, and evaluating interventions appropriate to the complexity of the problems and resources of the system. The CNS works closely with healthcare team members to implement and evaluate the most effective intervention based on a global grasp of the situation. Organizational strategies are developed based on the needs of patients, families, and healthcare providers.

The CNS creates an environment in which the daily pursuit of excellence supports clinical inquiry to improve clinical and service outcomes. Clinical practice is continuously evaluated and innovations for patients, populations, and systems are refined, based on experiential learning, the literature, and outcome and benchmarking data. The CNS provides mentorship to other healthcare providers in using and evaluating research findings to develop best practice.

Patient, family and healthcare provider education is based on individual, group and organization needs. The CNS, as a facilitator of learning, develops education programs with the goal of improving patient outcomes and quality of care. In addition, the CNS contributes to advancing the knowledge of the healthcare community at large and the practice of nursing through presentations, publications, and involvement in professional organizations.

The CNS collaborates with multiple disciplines to facilitate the achievement of intra-and interdisciplinary best practice. The patient and family are recognized as equal partners with the healthcare team and their contribution is integrated into their plan of care. The CNS ensures that collaboration at all levels occurs as the key to achieving optimal patient outcomes. The CNS is an expert at coordinating stakeholders across the organization to solve system issues.

The CNS is in an ideal position to help patients and families navigate a complex healthcare system because of their mastery of systems thinking. They assess, develop, implement, and evaluate care delivery models. In addition they guide other healthcare providers in using these models. They develop organizational strategies that are driven by the needs of the patients, families, and healthcare providers.

The CNS works to create an environment for patients and families where ethical decision-making and patient advocacy are the foundation. Healthcare professionals are mentored in the development of their own advocacy and moral agency. The CNS also facilitates the development of organizational ethics.

The CNS works with patients and families to establish an environment where caring is paramount and unnecessary suffering is reduced. This is done by ensuring that the physical, emotional, and spiritual needs of patients and families are met, even if those needs seem unfamiliar to staff. Staff are assisted in meeting these needs and are supported by the CNS in having their own needs met. The CNS is instrumental in facilitating an organizational culture of caring.

Patient and family values are incorporated into the delivery of care. Healthcare providers are assisted with gaining comfort with values that may be very different from their own. The CNS leads teams where members learn to appreciate the uniqueness of each individual and see the contribution that each makes in achieving optimal outcomes for patients, families, and the organization.

Model Case

The Synergy Model is robust in adequately describing the higher level competencies necessary of the CNS. How are those competencies demonstrated in practice? Consider the example of the CNS who leads a multidisciplinary group in the development, implementation, and evaluation of a conscious sedation program for a large metropolitan hospital system. The program goals include development and implementation of a policy, education of staff, and evaluation of patient outcomes. The first step in this process is a system analysis.

The organization is financially sound, is known in the community for its provision of excellent care, and has not experienced a great deal of staff turnover. The organization is a complex system requiring a policy that will meet the needs of diverse clinical areas. These include critical care, medical-surgical, pediatrics, psychiatry, and outpatient. Representatives from each of these areas bring their unique needs to the table.

The system is highly vulnerable because of the lack of a consistent standard of practice for conscious sedation. This lack of consistency may result in adverse patient outcomes. In addition, the organization may be found deficient during regulatory agency evaluation because the same standard does not exist in all patient care areas.

The state in which the organization is located is heavily penetrated by managed care; however, the system continues to deal successfully with the challenge of increased patient acuity, reduced staff, and the growing pressure of cost containment. Other similar programs such as restraints and seclusion and medication administration have been successfully implemented in this organization. The organization has dedicated technical, fiscal, and personnel resources that will contribute to ensuring a comprehensive conscious sedation program. All key stakeholders will participate in the development, implementation, and evaluation of this program.

Having evaluated the system characteristics, the next step is to match CNS competencies to the conscious sedation program. The CNS must be able to "synthesize, interpret, make decisions, and evaluate responses based on complex, sometimes conflicting sources of data." 2 There is a voluminous amount of information in the literature, benchmarking data, and colleagues, to develop the conscious sedation program. An evidence-based program also takes into account the unique needs of the organization.

The CNS is using all resources, such as the literature, benchmarking data, and colleagues, to develop the conscious sedation program. An evidence-based program also takes into account the unique needs of the organization.

The CNS facilitates the development of healthcare provider and patient education. Because multidisciplinary education is required, the CNS collaborates with patient / family and healthcare providers to develop a program based on learner needs. The CNS is an expert at collaborative relationships. Since the program must work for a diverse population, each person's contribution is crucial toward achieving optimal patient goals.

The CNS "uses expert knowledge of the system/stakeholders works with internal clients (eg, nursing staff, medical staff, other healthcare providers, administrators) and external clients (eg, institutions, sales representatives) to optimize the delivery of care" 2 for patients receiving conscious sedation. Ensuring a safe process for conscious sedation represents the concerns of the patient/family and healthcare provider. Conscious sedation provides caring practice by reducing unnecessary suffering during painful procedures.

The conscious sedation program addresses the needs of diverse clinical areas and patient populations. The stakeholders have differences in their approach to sedating patients. The CNS is able to identify the common thread for all patients and build consensus around that.


The Synergy Model provides a useful means to describe CNS practice in the new healthcare environment. This model takes into account not only the needs of patients and families, but also of healthcare providers and the organization. The model also elucidates the higher level competencies that the CNS must possess to successfully achieve optimal outcomes for all three spheres of influence. The Synergy Model has a great potential to link CNS competencies with measurable outcomes - something that the old definition was not able to do.


The author would like to thank her clinical nurse specialist colleagues at Sinai Hospital for their thoughtful contributions to this discussion.


1. Curley MA. Patient-nurse synergy: optimizing patients' outcomes. Am J Crit Care. 1998; 7(1): 64-72.
2. AACN Certification Corporation. CCNS Study of Practice. 1998.
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