Certification: A Strategy for the Future

A panel discussion at NTI '99 New Orleans
Moderator: Barbara A. Gill
Panelists: Holly Smith-Jones, Tam Leudtke, Bonnie Rice, and Kimmith Jones

This panel discussion has been edited for reading clarity.

Barbara: We want a lot of interaction, we want to hear from you and we have an incredible story to tell today at this session. This is session 484 in your class code. I'm Barbara Gill. I'm the Chair of Certification Corporation, and we are here today as a panel to show you how the Synergy Model, which is the model that we use in Certification, actually goes to work. How this model becomes practice, becomes management, becomes planning and becomes a source of pride for the nurses that are taking care of critically ill patients. Our panel today is made up of people that have put it to work — creatively, differently, some from the top down, some from the bottom up. These are real folks telling you about the Synergy Model in real practice.

Let me introduce you to the panelists. Then as we turn over during the course of the discussion, I won't interrupt our chain of thought. Our first speaker today is going to be Holly Smith-Jones. Holly Smith-Jones is a Consumer Representative who's been on the Board of CertCorp for three years, and she's kept us honest. I say that purposefully because, many times as we speak to each other and among ourselves, we tend to think of things — obviously — from the nursing perspective. The voice of the consumer that says, "But what about this..." is vital because they have a different perspective. Holly's a business woman, a California girl, a grandmother, but she says that she's the most hip grandmother there is in America. I'll tell you that she's right. Holly will bring us the patient-family perspective related to the Synergy Model.

Following her will be Tam Leudtke and Tam is the Nurse Manager of the Critical Care Unit at Hendrick Medical Center in Abilene Texas. It's a major healthcare facility in America. There are several represented here. It's also my hometown. Tam will tell you from her perspective, as a nurse manager, how she's been able to take the Synergy Model and integrate it into her life as a critical care nurse manager. She'll probably shoot me for this — I think she's been a nurse manager for 20 years. Doesn't she look great? She's amazing. So its clear, she's an experienced nurse manager to say the least.

Following Tam is Bonnie Rice. Bonnie is a staff nurse and proud of it! Bonnie has been a staff nurse for nine years — hurray for that. Bonnie's at All Children's Hospital in St. Petersburg, Florida. She's going to give you the perspective of how her unit has literally brought the Synergy Model from the nurse level up to patient care and into the management system. It started at the staff nurse level. Bonnie has an amazing story to tell. She describes the Synergy Model as a dream come true and I'm going to let her explain that to you in a little while.

Kimmith Jones, who's directly behind me, is the Chair-elect of the Certification Corporation Board of Directors. He's a practicing clinical nurse specialist (CNS) at Sinai Hospital in Baltimore. Kimmith will talk about the CNS role and how the Synergy Model integrates into his philosophy and his practice. Just to help us know who you are, how many of you are nurse managers? How many of you are staff nurses? And how many of you are CNSs? All of the specialties are well represented. This panel will provide something for everyone.

I want to take a few minutes and give you a framework for how the Synergy Model came to these kinds of folks. How does a model get adopted by an organization, researched and brought forward so that it can be tested in the practice arena? First I'm going to give you some definitional terms and then give you the chronology of how it worked through Certification Corporation and AACN to the level that we are today. I would like to start with the definition of certification. The Synergy Model came from the Certification Board as we were looking for a model. Certification is an accepted method of validating an individual's qualifications — it's not particular to nursing. Somebody was talking the other night about how they made a decision when they opened the Yellow Pages and needed a carpet cleaner and chose a certified carpet cleaner — it said in the Yellow Pages. Well you laugh about it, but the term certification indicates to a consumer, to the public, that there's an individual that has a certain level of qualification and knowledge to provide the service that they provide. So not to compare critical care nursing with carpet cleaning, but the term certification is a term that sits in the public arena. It's a consumer issue? We have certified public accountants, we have certified estate planners, we have certified carpet cleaners and we have certified critical care nurses. It indicates to the public that the individual has certain qualifications and knowledge for practice and, in our situation, in a specific clinical area. That's the definition of certification that we use as a foundation of our work.

What does certification actually do in healthcare or for critical care patients and families? Well, it should serve as an assurance that consumers — the patients and families — are receiving care from practitioners who have several characteristics. The certified deliverer of care has defined experiences. This is going to sound familiar to those of you that are certified. This is how the qualifications read for your certification exam: that the individual has defined experiences, has educational qualification and necessary skills. Now does this say anything about excellence? No. It doesn't say anything about excellence. Certification can't define or assure excellence. What it can define and assure are qualifications, education, necessary skills and experience. Now what happens if you have those components? You tend to be a better practitioner, right? However, we can't know each of you individually to evaluate excellence. What we can do is set a standard which needs to be met. So, then what does a certifying agency do? AACN Certification Corporation is a certifying agency, and what our group does is to guarantee, and we can use that word, to guarantee that the process of certification is valid and reliable. The process is valid and reliable. So if there are individuals that have the qualifications and we've worked diligently to make sure the process is legally defensible, statistically sound, we have a match. That translates to the public. Certification Corporation has in the past, and continues to redesign certification, to keep it relevant to the clinical practice of today. Now there are a few of us that have been around a little longer than others, that took certification exams ten years ago or fifteen years ago. The exam is updated, okay. The relevancy responsibility is the certifying agency's job, so it's continuously updated to be relevant to practice. We want to be sure that the certification itself links with what's going on in today's nursing practice. Those are our jobs. We maintain relevancy through the subject matter experts; we do it through the exam development committees; we do it through test modeling. I learned a new word in this position: rubricing - to make sure that the exams themselves are linked to the behaviors and to the practices that need to be tested. Hopefully, this explains to you what certification is and what the certifying body does.

The next step is to figure out how you're going to get the exam to the people that want to take the examination to become certified and the people that want someone certified caring for them. To accomplish this you need a model. We started working on the model. Now, traditionally, the model for certification was divided into body systems. This was at the time a very reasonable model. It dealt with physiology and body systems, and it dealt with primarily a medical model that said a pH is between here and here and normal PA pressure is between here and here. It also dealt with geography. That geography consisted of the fact that the nurse practiced in a critical care unit. Now that made sense for a long time. But then guess what? We started recognizing that as times changed and technology changed, nursing changed and consumers changed. There were some pieces missing. And, we didn't really have the individual patient or family in the model. We had body systems and geography. We needed to figure out, as part of our responsibility to keep relevant, how we were going to update the model for certification. What were patient needs, other than a normal pH? Where did the family fit in? What were the dimensions of the nurse? The nurse was missing. There was nothing that said to you as you studied or took your exam: What's normal for a nurse? What's expected? What's identifiable? We looked at the patient's body systems, but at us as healthcare providers. What kind of practice should stem from patient needs? Those questions became more and more relevant and a think tank was organized. Pat Moloney-Harmon and Martha Curley, both original think tank members, are present today. Nursing experts from around the country came together as a think tank to try to answer the questions I just reviewed for you.

So that's where the descriptive language and the terms that you all have started to hear and learn and apply began. Resiliency, caring practices and systems thinking are examples of terms that developed out of that initial think tank. This group of experts recognized that there are identifiable patient characteristics, and there are identifiable nursing characteristics. Then you had to test it. Ten good nurses couldn't make the decision; it had to be tested. In 1995 Certification Corporation sponsored what was called the Study of Practice. Thousands of nurses were randomly pulled  and they were critical care nurses, not necessarily AACN members or certified nurses. What was done was a Study of Practice which used patient care scenarios and the definition of terms to see if, indeed, nursing characteristics could meet patient needs, and better outcomes in terms of the decision process for the patients would occur. Guess what the Study of Practice found? It found that the terms that the think tank had proposed were valid and reliable. The statistical analysis of this is all available to you on the bib list. Indeed the terms and the criteria and the continuum that both nurses follow and patients and families follow was validated by the Study of Practice. At this point we had a model that had been updated; the physiology was still there, the body systems are still there, but we did away with the geographical boundaries and we put the nurse and family in. People started getting panicked: Oh, my goodness, how am I going to study for the exam? What else is in our lives that we know about — in our practices that we know about? It is time for nurses to acknowledge all the defining characteristics of patients and families and their needs and what we do as nurses. As the exams evolved, the Synergy Model was folded in. Just like it's folded in all of our practices every day. I want to stop there, because hopefully now you feel like you understand the historical development of the Synergy Model. We had a validated philosophy. We had a concept that had been tested. So now the question is: Does it really work in real practice? Does it become meaningful for patients and families, nurse managers, staff nurses and CNSs? We'll let the Panel answer those questions.

Holly: Let me tell you a little bit about myself. I am a Theater Arts major who happened into a business career. I am a liberal arts person and not a scientist, nor do I have any kind of science background. I had worked with AACN for a number of years on some of your insurance programs, and three years ago was invited to apply to be one of the consumer representatives. Joan O'Sullivan and Virginia Oleen, two other consumer representatives are here this afternoon. I thought, "Oh good. I love this association. What fun this is going to be for me." I came to this first meeting and to the orientation and I was a little bit nervous, but I thought this would be okay. One of my first big questions was what exactly was a CCRN? They explained that very nicely to me. Then I said, "Well what would happen if I just ask for one when I go to a hospital? What happens if I go in and say, 'Well is my nurse a CCRN?'" There was silence, and I thought, "That's not good." I would never go into a situation that was life-threatening and not have a board-certified physician, because they've made that so much a part of how they market physicians. So this has become my great mantra during the years I've been on the Board. It is my goal to discover how to bring certification into the forefront in the community, so that people will automatically ask for it and you'll get the validation for it.

So anyway we get through that and then all of a sudden they have this Synergy Model and I think, "Hello? Theater Arts degree — I don't understand what the Synergy Model is." It was scary to me. Like many of you I looked at the new model and thought that they had changed everything. What does this Synergy mean, how is that going to translate? The more I learned about it, the more I learned it was what critical care nurses were already doing. I guess my real role up here is to share a few stories with you that show you what is synergistic and what is not synergistic.

The year before I joined the Certification Corporation Board, my mother, who had been chronically ill for years and years with a great deal of complications, had a series of transient ischemic attacks (TIA) and was taken down to Green Hospital at Scripps in La Jolla. She was 75 years-old. My dad was nine years older than she was. They had had long discussions that they did not want heroics done for life at that time. To live longer and not have quality of life was not where they wanted to be. They're both very intelligent people; however, when it comes into your life and all of a sudden you're having to make these decisions, all that intelligence flies out the window. The nurse becomes the life raft that we grab onto that helps us communicate. I knew the last weekend I was down with my mom before she died, that she didn't want any heroics. She had lost whatever her swallowing reflex was, so she was aspirating food; she couldn't eat and she could barely talk. She was trying very hard, and she could barely write, but you could just hear her saying, "I want out. I want out." All of this happened to happen over a weekend when her regular physician, who they'd had all these conversations with, was out of town. I told this one nurse, "You know my parents have a living will, they don't want any heroics." This woman looked at me like I was taking a dagger into my mother's chest. I thought, "Whoa." Okay, I'll talk to the doctor when he gets back into town, but it made me feel badly. I didn't want to see her go into some kind of emergency acute situation and be put on a respirator, and then we'd have to go through the whole thing of taking her off, which I guess is a whole other issue. This situation was not synergistic. She was not empathetic; she was not thoughtful; she was not collegial. Who knows where she was coming from, but this is how I heard her; this is what I was feeling.

The next day I came back and I brought my dad back with me. There was another nurse there caring for Mom and I said, "You know I'm really concerned about where all this is going." She asked my dad and I to come into a conference room and we talked. This was my father's decision — whatever happened was my father's decision. They'd been married 54 years; they were the love of each other's life, this was their decision. Whatever they said was going to be okay. She took us into this room and she sat us down and she said here are some decisions you're going to have to make in the next few days. Clearly, your wife can't eat, so we're going to have to put a feeding tube in her. They were going to have to do some kind of trach to assist her breathing, which meant she wouldn't be able to talk. She would not be able to come home — probably ever — and would be sent to a nursing home where she would be helped to breath, couldn't talk and be fed through these tubes. The nurse said, "You don't have to make this decision now, but the doctor will be back in a couple of days, so think about it."

Dad was able to go home, talk to some of his best friends, to the family, and really say, "Okay, this is what she wants." Your first reaction is do whatever you have to do to save them, no matter what decision you've made, you just say, "No, no, not time yet; not ready yet." He was able to have this conversation, and then the doctor came back and this wonderful nurse. We sat down and Dad said, "You know, this is her quality of life." He was 80-something at that time, and he's still around at 91 and in great health, but he's frail. Ninety-one is frail. He couldn't take care of her, and to have her just sit there; he knew he couldn't look at it. We were able to just let her go. She died a day later and it was the most peaceful time. The outcome certainly wasn't what we wanted; we wished we could have saved her. This nurse helped us do it in a timeframe and in a thoughtfulness that brought us back to where our intelligence was so that we weren't dealing totally with this emotion. So that's story #1. That's synergy to me. They saw what we were needing. They needed to hear; you needed to hear from us what we wanted. We couldn't articulate it until you told us how to take the time, to take the deep breath needed to do it. So it was a wonderful experience, if that can be that.

Then last April, my very best friend from high school was about to become a grandmother for the very first time. We were so excited; we just couldn't wait. I happened to be back East at the time this happened. Her son called and said, Christine's gone into labor." And, he said, "there's a lot of blood there, but the doctor said don't come in, because we're switching shifts now, and it's just normal." Well this is a first time child — they didn't know and there was blood. There was a lot of blood there. Sue, my friend finally said, "Don't listen to them. Take her in." They were there within an hour of the time that this accident began to happen. I don't know the exact details, but the artery in the umbilical cord had ruptured, and the baby bled out before they could get her there. They had to do a C-section, and Sierra was born alive, but clearly very damaged, and with not very much prognosis for a good return. Well, the kids are in shock. I mean, here's a full-term, wonderful pregnancy, healthy baby that is born and she's not going to live, and if she does live she's going to be horribly handicapped. The nurse is really wonderful, working with the parents, but she saw they're just clearly not getting through to the parents. They found out where Sue and her at-that-time estranged husband lived. They called them and said you've got to come in here. We've got to talk to you. We have to tell you what your children are facing so that you can help them go through this. They're denying the fact that this baby is dying. They went through this wonderful conversation with them. It let Sue and her husband put their arms around these two children, and hold on to this baby until she died. It helped make a terrible situation optimal. Happy news, she's going to have a baby in August now, and she's going to go in early and have a C-section — no more of this other stuff. These terrible, life-altering experiences were made so much better. Even coming out of that, Sue was able to say, "Everybody just took such good care of us." That is synergy. So that's what I have to tell you.

Tam: It's a pleasure to be here this afternoon, I'm glad to see so many people interested in finding more out about the Synergy Model. I'm very excited to hear Bonnie's presentation. She is much further along in the process than I am. A lot of what I'm going to talk about today is works-in-progress. I have a director who's very good to work for, but he believes in evolution, not revolution, which is a little hard for critical care nurses sometimes. He believes in inoculations, so we are moving through this process. I'm working at the staff level with the nurses from the standpoint of assignment-making, but also working at the director level, because I would really like to see the Synergy Model accepted across the continuum of care at our hospital.

I first got the Synergy Model because Barbara brought it to me in her hand. I'd been working with her for a few years, and I found out a lot from her. If she shows up with handouts I'm usually in a lot of trouble. There's going to be a lot of work. I've also found that when she shows up with any information, any questions, every time it's resulted in better patient and family care. I really feel that's going to happen with the Synergy Model also.

When I went to nursing school, which as Barbara said, was awhile ago, I started out as a diploma nurse, and they warned me that there were nursing models. "There are going to be nursing models out there. You're going to have to listen to them." I went back for my BSN and they made me use one, but it was one of their choosing. I went back as the master's and they made me teach one. At least I got to pick the one I wanted to teach a class about. These nursing models often make us as nurses wonder, "What are these people thinking?" As I read about the Synergy Model, it was very clear what people were thinking. It made perfect sense. It fit, very much, with what I did on a day-to-day basis, which was the first thing Barbara pointed out to me. I said, "What is this all about?" She said, "I see you do this every day." So I thought, This has got to have some merit. If this is what I do every day, it must be good." I stopped and really thought about what it meant to me to relate to my patients and families and what I believed about nursing. It's one of my favorite questions in an interview: What do you believe about nursing? What is your philosophy of nursing?

Well, I had to think about that for myself, and what I really found out is that I believe very strongly that the patient and family should be the center of everything we do. I had a couple of staff members here, and they would tell you that when they come to me with a conflict or a concern, the first thing I tell them is, "What's in the best interest of the patient? What is the best decision for this patient and this family?" So, it was already part of what I did. Another thing I preached all the time is, "We've got to match our available resources to the patient's needs." I only thought about this from a much more global standpoint. I thought about how we get them to the right room, how we get the right resources, how we get them to where they need to be, to get the right interventions. I see a lot of head nodding. You go through this every day. Well, it just made sense to bring that down to the unit level. I really had not thought about that before. I mean, I'm one who really does think about assignment-making, and I like to know the reason behind why assignments are made, but I hadn't really though about it in terms of matching the resources to the needs. It's the same thing.

So, what do you do? How do you start out? How do you operationalize this model as a manager? Here are some examples of practical applications. You can use this as a framework to develop a vision statement, to develop competency testing, to link patient needs to nurse competencies (which is the heart of the model), to measure performance and measure outcomes. Those are things that we do on a daily basis as managers.

Why is it important to have a vision? If you all listened to Mary's talk at the beginning of the NTI week, she talked about having a vision, and how it was important that everybody work toward common goals, that everybody had the same understanding of what the goal and the expectation was. Everybody needed to know how to get to the goal. That's why you want to have a vision. You want to have a guiding philosophy, something that articulates the values and beliefs of your unit or your hospital. You could just adopt the AACN Vision, which is an excellent vision and obviously supports the Synergy Model, but for us I wanted to try to develop a different vision. Sometimes in our hospital, critical care services is sort of referred to as the whiners. Those nurses always want to change things. They always ask, "Why?" They always ask, "What are we doing this for? And, why are we doing it the same way?" We say, "Thank you. You're right. We do." We would like to see people have a similar vision across the continuum, and searching for answers — not just be something that critical care services did. This model really provides a good framework and a good background to develop a vision statement. If you use the tenets of the model to look at what your vision could be, you would think about things such as that the patient and family characteristics drive the nurse competencies. That's part of the model. Then, the competencies of the nurse are matched with the needs of the patient, and that's when you have synergy. When you have synergy, you achieve optimal outcomes. So what you're wanting to do again is have a patient and family-driven system, you want to have the competencies of the nurse meet the needs of the patient. When those things happen you have better outcomes.

It also says that the patient with the greatest level of need requires nurses with the highest level of competency. I think we kind of knew that, but it's nice to have it written; it's nice to be able to use this to show people why it's important that we have well-trained, skilled nurses working in the critical care unit. If you look at the total Synergy Model, what it said to me was that it was patient-focused, that it's relationship-centered, that it recognizes the uniqueness of individuals, that it's a holistic, caring practice based on patient and family needs. Those are important things to me and those are good value statements and good beliefs to base a vision on.

Now a few words on utilizing the Synergy Model for developing competencies. We all have to do competency testing. If you have anything to do with Joint Commission, you know you have to do competency testing. We have an excellent educator, but a lot of the times she still has to do pre-test, class and post-test. What does that really tell you about the nurse's ability to go out and take care of the patient? It tells you that the nurse can come in and take a test and do really well if she's just had a good class on it. It doesn't really tell you that she or he can go out and take care of the patients. If you follow the Synergy Model you can develop case-study scenarios based on your nurse-to-nurse shift reports. You can actually use your own patient population so this makes sense to the nurses, so that they understand the kind of patients they are taking care of. Incorporate all of the nurse characteristics that are in the Synergy Model; don't just test clinical judgement. Don't just test their technical skills, but look at their advocacy; look at their caring practices. Look at their ability to take care of the patient as a whole. You move away from just doing fact "yes/no, no/false" repetition questions, and really move into analyzing critical thinking skills if you use this kind of scenario.

This would be a little bit of a slower process, I would think, and I'm interested to see how this works with Bonnie. You're going to want to link the patient's needs to the nurse's competencies on a daily basis. To do this you're going to have to know what your nurses are able to do. You know that already. Already, don't you really know, when you think about your nurses, do you tell yourself, "This one really has it up here, in her head." Or, "This one really has it here, in her heart." Or, "This one really has it here, in her hands." We all have nurses and we know how to divide them, and we know what their skills are. Well, if we begin to use the Synergy Model we can identify patient characteristics during report, know the level of the nurse related to all of the competencies and assign the nurses accordingly. How many times do you come in as a manager and you ask about an assignment and they tell you, "Well, she was there yesterday. That's why I put her back there today." That's not necessarily a good reason. My favorite is, "I didn't have a choice." I hate that one. There's always a choice, and you really want to be sure as a manager that your staff, your charge nurses, are assigning your nurses according to what the patient's needs are, and Synergy is a way to do that.

I think complementary care is still very important, but I don't think it is the be-all and end-all of assignment making. The patients change so quickly in critical care that sometimes the condition of the patient becomes so much worse. How many times do you give your newest nurse the easiest assignment and they crash? You really have put the newest nurse into a situation that she is not capable of handling. Do you just leave it that way because you want to be sure the same nurse is there or the same nurse is caring for that patient? Not always. You need to still consider whether that's in the best interest of the patient or not. Now sometimes if there are not real high technical needs, maybe the nurse you need there is the one with the most caring practices, the one who can best relate to a patient and family from the standpoint of easing the dying process. I think it really depends on what the needs of the patient are, whether that's a nurse you're going to leave in that situation or not.

Audience member: But doesn't that also mean you need to educate and support that nurse, otherwise that person will never become capable of handling those situations.

Tam: You are looking at the needs of the entire unit when you do that. You have to know as a charge nurse or a nurse manager you're going to be able to be there to provide that support and support that learning situation for that nurse. If you've got 15 critical patients it's going to be harder than if you have a more stable or a lower acuity number that day. You have to make those decisions on a day-to-day basis, and those are very good points and you do have to keep those kinds of things in mind. This doesn't make everything that we've known before go away. It really just complements it, though.

I do think you can use the Synergy Model to develop performance appraisals using the nurse characteristics. I would encourage you to use all the nurse characteristics, not just focusing on clinical judgement. Now, Friday before I came — I'm a volunteer on the Practice Advisory Team for AACN — I received in the mail the nursing standards for acute and critically ill patients. They're great. They're going to make the basis, I think, of a very very good evaluation process for nurses. They're based on the nursing process and they incorporate the Synergy Model. They talk about evaluating the nurse on her ability or his ability to apply the nursing process, but they also talked about professional practices, ethics; they talk about collaboration; they talk about education. I believe it will form the framework to give us the ability to really set up a professional practice model within an institution. What you might want to do is use that more for the basis of an evaluation, and move more with the Synergy Model statements into a clinical ladder. The good thing here is the work is done. It's been done by some really, really smart people and it's really good work, and you just have to adopt it and use it.

The level 1— if you remember the nurse characteristics are across a continuum — in level one is your beginner nurse, and you're talking about clinical judgement. They've defined it as collecting basic data, including extraneous details. I think Bonnie's going to talk a little bit more about this. Level 3 collects and interprets complex patient data, focuses on key elements of the case while sorting out extraneous details — it's your intermediate. Your expert nurse synthesizes and interprets multiple, sometimes conflicting, sources of data, and recognizes and responds to the dynamic situation. You can also think of examples, probably, in your unit, of nurses who fall into these levels right now. This would be a good way to evaluate your nurses and a good way to move along the clinical ladder.

You can also develop outcomes assessments; it can be patient and family-defined outcomes. Functional change: Did the open-heart patient who wanted to go fishing with his grandchildren really get to do that in six months? Did the hip-replacement patient get to walk a mile, like he planned on? Trust? Satisfaction? You're probably already collecting that data in some sort of patient survey. You will have data in that case to compare before and after implementing the Synergy Model. Comfort: Is the cancer patient really under good pain control? Behavior: Did you really make a difference in lifestyle changes in the patient? Did the cardiovascular patient stop smoking? Did he change his diet? Did he get more exercise? Knowledge: Does your diabetic patient know about good foot care? Does he know how to give insulin? Details of his diet? Those are things that are really easy to evaluate, and you would have some data on that already so you could compare pre- and post-implementation of the Synergy Model.

Care-giver assessed outcomes, physiological changes: Did the patient come off oxygen when they were supposed to? Presence or absence of complications: Did they develop wound infections? Did they develop ventilator-associated pneumonia? Extent to which objectives were obtained is measurable: Now, remember, when we're talking about the Synergy Model this is patient and family-defined objectives. I think one of the most important things about the Synergy Model is that it recognizes the patient and family as partners in healthcare. It gives them equal responsibility for establishing and meeting outcomes. It's very important that it's not just our objectives and outcomes that we're looking at, but we're looking at the patient-defined ones.

Systems outcomes, recidivism: Did the patient with congestive heart failure get readmitted again? Cost, resource utilization: What is the length of stay in the critical care unit? Those are all things you can look at and hopefully begin to show changes associated with the use of the Synergy Model.

Why would I, or anybody, want to go through all this work? As a manager you have plenty to do. One of the things I find with the rapid changes in healthcare delivery, on a daily basis I seem to be responding to the environment; I'm running around responding to whatever's happening at the time. The Synergy Model would give you an opportunity to shape the environment, not just respond to it. You could shape the environment within which you provide care to your patients, within which you work every day. The Synergy Model provides the means to maximize our resources. This would give you an organized method for your charge nurses to utilize their staff, so everybody was making decisions in an organized manner, and not just sticking names on a board. You could really maximize the talents of each of your staff members, because you would be more familiar with what their talents were, what they did best, whether they were the head or the heart or the hands nurse. You hope you have someone who's all those things, and eventually you do, but there are always those people who do one thing a little bit better than another. This is a good way to maximize what they do. More importantly, and I think the most important reason, is that we do have an obligation to our patients and families. You've heard it repeated over and over again, that we have to provide them safe passage through this maze of healthcare. I think that is the most important reason to look at adopting the Synergy Model. Thank you.

Bonnie: Hello and thank you. I'm a little nervous, but I figured I couldn't be in better hands in case I have a cardiac arrest. I'd like to share with you the series of events that resulted in me becoming a speaker representing staff perspectives of the Synergy Model. In 1995 I attended an AACN meeting in Orlando, and I saw Barb Gill begin to introduce the Synergy Model. Then in 1998, January, in case you want to look up the article, the original Synergy article was published in the American Journal of Critical Care. I read the article with interest, but I really didn't try to apply it to my bedside practice at that point, but all the things in the model — the nurse competencies — looked familiar to my bedside practice. In the Spring of 1998, I was called from my bedside position to sit on a think tank of staff nurses to try and revamp our career ladder — our clinical ladder. We were asked to define what nursing looks like at All Children's and what All Children's nurses think a good nurse is. How did they define a good nurse? So to do that, we decided to pass out questionnaires that were very open-ended, and we grouped the like responses that we received. A lot of the nurses' responses indicated that they wanted a nursing model in which they could validate their practice. We took the nurses' descriptors and we began to search the literature for a model of practice that espoused similar characteristics and values. Nursing models have historically been perceived by bedside nurses as kind of barriers. They're difficult to intrepret, they're abstract and they're barriers to the engagement that occurs between nurses.


It is the emotional, caring component of the profession that was the very impetus for most individuals to enter into nursing. All Children's nurses stated emphatically that caring about patients and families is how they define themselves. Unfortunately, caring is difficult to quantify and the worth of a registered nurse has been questioned. In light of this, nurses must be fluent in the language of cost as well as caring, and cognizant of ways to demonstrate their unique contributions. The Synergy Model supports All Children's philosophy of professional advancement. It describes patient characteristics, matching well with the nurse competencies, resulting in optimal outcomes. The Synergy Model, which is important for our hospital, All Children's, because we also do adult open-heart there. It's adaptable to all areas of practice, and it has been adopted hospital-wide. It's even adaptable to practice outside of the acute care setting, from the primary care provider's office all the way to the operating room. It also encompasses all age groups, whether it's neonatal, pediatric, adult or geriatric.

Synergy places the patient on a variety of continuums, reflecting not only the holistic and dynamic nature of the patient in a time of physiologic instability, but also recognizes the family and the community as essential components in determining a patient's outcome. Another clear and desirable aspect of Synergy is the definition of eight specific nursing competencies. I do want to clarify the term competencies — these aren't things that you do for your yearly evaluation. These are behaviors. This model is behavior-driven. Things you'd see in a good nurse. These competencies put words on what we do; they allow us to speak to what we do. The concrete description of the competencies provides us with the template to dissect our actions, for professional introspection and growth.

Nurses really function on a level of professional intuition. Then we go home at the end of the day, and who's ever there — whatever significant other — we kind of go over our patient experiences and talk about them. If you'd take this model and sit down with your patient experiences, you can identify patient characteristics. They'll jump right out at you. You can decide on what your competencies were that matched those characteristics and look at your outcomes. In evaluating those outcomes, you identify whether those things you wanted to happen did. If not, you know where you need to grow. This is a great tool for professional introspection. That's why we really wanted to use it for our clinical ladder, because we want to grow professionally.

To introduce Synergy to our staff, we've used a variety of methods. We really introduced the model before we brought out our career advancement program, because we didn't want them to get confused that this was just going to be the basis for our career advancement program. It's adopted as our model of nursing, so from the day you're hired on, 'til the day you resign or retire, you're going to see the Synergy Model in all our documentation and measurement tools. We wanted to avoid holding large staff meetings where nurses would be pulled away from their patient assignments, often increasing their stress levels, so we decided to pass the model on mostly by word-of-mouth, from bedside to bedside, unit to unit. I do want to point out that administrative support has always been visible at our regular staff meetings, and there's also been some resource allocation that they've approved. We used tri-folds, we used fold-out displays, we used stickers, we had cafeteria days and we also distributed information with the coffee and donut cart unit-to-unit, which was very nurse friendly. We made sure to include all shifts in the process, some nights we went around all night long. Nurses would say, "This is from nurses, for nurses?" You know, they kept trying to give the donuts to the parents. There's a lot of excitement about Synergy because of its' direct applicability to bedside care. It defines what a good nurse looks like at our hospital. The staff has a clear picture of what behaviors define a nursing expert — real important for your staff — how good is good enough?

We still have a significant amount of work to complete. The new clinical advancement program will be introduced and implemented this year. For more information specifically on how we delineated or differentiated practice in terms of the competencies, there should be an article coming out in Critical Care Nurse at the end of the summer and that will actually have one of our examples in it.

We also are working on our competency-based orientation tools, so as we Synergize that, new employees can better set off on a career path of success. They know what directions to go in. We've started to develop new formats for our protocols, our policies and procedures and I understand there's standards of care available.

Barbara:  think they're already on the Internet. Printed copies are going to be available in a couple of months.

Bonnie: Eventually I would like to see our documentation system be Synergized, and also some form of acuity assessment. I think that's what we're getting to, assessing our patients and their characteristics and then matching up the nurse with the appropriate competencies.

So, in conclusion, what's the bottom line? Synergy is an innovative solution to define, recognize and reward progressively developing nursing expertise at the bedside. Clinical experts must be mentored and rewarded if we're to provide safe passage for our most acutely ill patients through the healthcare system.

The end, and thank you.

Kimmith: Hello. Is some of this starting to make sense a little bit? Yes, it does. Can you see, and do you think that this has applicability in the advanced practice nurse arena? Absolutely! I believe that, and Certification Corporation believes that as well. As a result of the Synergy Model development, the Certification Corporation has developed and implemented the CCNS credential — the Certified CNS credential, with the foundation and the framework of that program being the Synergy Model. Now a little bit about the test itself — it started in January of this year, and it consists of about 150 items. Those 150 items are core competencies for all CNSs within critical care. Then there's an additional 25 questions that the nurse taking the test selects, depending on what his or her specialty is: meaning, neonatal, pediatric or adult. So those are the categories of the test and how that actually works.

How have we incorporated this into our advanced practice role at Sinai Hospital in Baltimore? Well, a little bit about our facility and about our group. We have a collaborative practice group. And within our practice group we currently have eight CNSs. Our whole group is responsible for certain clinical outcomes within the facility and each of us is responsible for the clinical outcomes within our specialty area. We report to the vice president of nursing and work very collaboratively with the directors of Patient Care Services for our particular specialty area. What's very interesting is that, probably four or five months ago our vice president asked the advanced practice nurse group to really look at the Synergy Model and to see how we can incorporate it into the department of Patient Care Services globally within the institution. We started this conversation with administration probably about a year ago, and now we're to a point where they would like a definite plan of how we're going to implement it. This is very very exciting news.

So how do we, as advanced practitioners, really incorporate this into our daily practice? Well, remember that this whole thing is based on these nurse characteristics in this continuum. These are dimensions of practice that go from basic to expert, and these dimensions are driven by the needs of patients. What's very exciting about this whole model is that it really describes the unique contribution of the nurse to the patient care team. By looking at these nurse competencies we can articulate our unique contribution, which is sometimes difficult to do with previous models that we've used.

So let's take a look at these nurse characteristics, the first being Clinical Judgement. Clinical Judgement is defined as clinical reasoning — which includes clinical decision-making, critical thinking and a global grasp of a situation — coupled with nursing skills acquired through a process of integrating formal and experiential knowledge. So as you first read that and think about it you might be thinking, "Oh, good Lord, what does that all mean and how do I do that in my daily practice?" Well, when I look at my practice I can see how I actually do this. One of the things that the advanced practice nurses are responsible for in our facility are these things called ICRs (Individual Case Reviews). We get those through the risk-management department whenever there's some type of an outcomes that may not have been as optimal as they should be. Our responsibility is to take these ICRs and reconstruct the situation, to put all the pieces together to see whether or not nursing practice was appropriate, what alternatives could have been identified to maybe change the situation a little bit. The next step is to develop an action plan to correct it for the future. That is one situation where the APN looks at the whole environment, the whole situation and critically thinks about it to see what we needed to do differently for the future.

A second one of these nursing characteristics is Advocacy and Moral Agency. This is defined as: working on another's behalf and representing the concerns of the patient; serving as a moral agent and identifying and helping to resolve ethical and clinical concerns within the clinical setting. Now, interesting with this characteristic, there's an added dimension. The added dimension to this is the staff. As you know, clinical nurse specialists spend a lot of time directing or working with staff in order to affect patient outcomes. So we have to think of Advocacy and Moral Agency not only as speaking up for the patient and family but also, as advanced practitioners, speaking up for the staff. An example of how I've done this in my practice, was a situation where there was a patient in critical care and the person was extremely sick, and the family had the interest in withdrawing support and letting this patient pass away. They did not feel comfortable approaching the physician and the staff did not feel comfortable as well, so they're bringing the team together, and talking about these very very difficult issues. As an advanced practitioner, I brought the team together and helped to open up the dialog and get these issues out and have the physician really understand where the patient was coming from, what the staff was feeling, so that we could have a dignified death for this particular patient.

A third nurse characteristic is that of Caring Practices. Caring Practices is defined as: the constellation of nursing activities that are responsive to the uniqueness of the patient and family and that create a compassionate and therapeutic environment with the aim of promoting comfort and preventing suffering. So, do we do that as advanced practitioners? All the time. One situation comes to mind in particular, and this was a patient, again, that came to the intensive care unit, and this particular patient was a trauma patient, and had a severe head injury. The patient came into the emergency department, went to the operating room and then was in critical care. The staff was expert at caring for the patient in the bed, monitoring vital signs, looking at IVCs and intercranial pressure. While that was taking place, there needed to be someone to talk with the family. I was available, so I offered to do that. Taking the family to a private room and just helping them understand the situation and just sitting there and letting them express their concerns and thoughts about this whole environment and this whole situation was very important to them at the time. And it's not that I said a lot of anything, I was just there for them and listened to what they have to say. Later on — probably three or four days later — they came up to me and thanked me for that opportunity just to sit there and listen, and that was very stress-relieving for them and helped them to get through that initial crisis situation. The same is true for staff. Staff need that time also to verbalize their concerns, and I find myself quite often listening to staff one-on-one about their concerns of taking care of a particular patient or a particular population of patients or just the environment itself. It's amazing how many times they say, "Thank you so much for letting me talk about the situation to you." It's not that I had a lot to say or a lot to offer to them verbally. The caring practice of listening provided the relief.

Collaboration is another nursing characteristic. Collaboration is defined as: working with others in a way that promotes and encourages each person's contributions toward achieving optimal and realistic patient goals. This includes intra- and inter-disciplinary collaboration. We as nurses do not do things in a vacuum whatsoever. We have to have other disciplines involved in what we do so that we can promote and improve patient care. One way that I've operationalized this is through implementation of patient protocols within the emergency center and the emergency department. We moved to a brand-new facility probably a year-and-a-half ago, and at that point in time we had no set protocols for patient care. By pulling a group together of physicians, nurses, respiratory therapy, we were able to identify and develop 14 patient protocols. So now when patients come to the center they're put on a particular protocol that can be initiated by the nurse before a physician sees them so that we can initiate care and hopefully improve their outcome and get them through the system a little bit quicker.

Systems Thinking is another nurse characteristic. Systems Thinking is defined as: the body of knowledge and tools that allow the nurse to appreciate the care environment from a perspective that recognizes the holistic interrelationships across the healthcare system. So, do we as advanced practitioners utilize the system in what we do? Absolutely. Many of us have house-wide responsibilities and initiatives that we work on. One in particular that comes to mind that is an ongoing process right now. It is that of a blood bank process improvement team. We've had some difficulty in getting blood products to patients in a timely and efficient manner. We are in the process of developing a form that's user-friendly that we can facilitate this whole process with. A process was initiated about a year ago — it was not that successful, to say the least, so we needed to reconvene this group and move things forward. I helped to pull that team together and are in the process of piloting a new process and a new form. Hopefully this will be very successful and I'm encouraged that it will be the major thing that we do. Another Systems example that comes to mind is that of an emergency center. As I said earlier, we opened up a brand new emergency center about a year-and-a-half ago. As the advanced practice nurse, I was extremely involved in movement of patients through this new center, looking at the technologies that needed to be available to improve patient care and to make sure that the standard of nursing practice was where it needed to be. We have been able to see — truly — night and day differences between the old facility and the new facility and the new processes that we have in place.

Response to Diversity is the sixth characteristic. Response to Diversity is the sensitivity to recognize, appreciate and incorporate differences into the provision of care. An example of this is a patient with a respiratory problem, who again was in the intensive care unit, who was able to let us know that he was an IV drug user. Now, this is a diversity issue because there are some nurses that may not feel comfortable taking care of patients who are IV drug users. We were able to help the nurses understand this particular patient problem, and gained consensus on the best way to care for him and to help them through that issue. The final outcome being that he was able to get on the methadone program.

A seventh characteristic is Clinical Inquiry and Innovator/Evaluator. This is defined as: the ongoing process of questioning and evaluating practice, providing informed practice and innovation through research and experiential learning. We do this every single day as advanced practitioners when we ask the question, "Why are we doing this the way we're doing it?" Truly, everyone in this room can probably think of an example of how you relate to this nurse characteristic. One thing that comes to mind for me is within the emergency department and documentation. I mentioned earlier about moving to a new facility. When we moved to a new facility we brought with us an old documentation system which consisted of several different forms that the team had to document on in order to get the patient through the system. A nursing notes sheet, a physician order sheet — it was just incredible the number of forms that the team had to document on. Probably about four or five months after being in the facility, we started to jump on this particular issue. The final outcome being the development of a flow-sheet — a four-page flow sheet — that has all the information on it that we need to have to care for this patient. It's using the [inaudible] charting by exception as a framework. We've been able to decrease the time in documentation and save the nurse time in order to better take care of their patients.


The final nurse characteristic is Facilitator of Learning of Patient, Family and Staff. We utilize staff a great deal in what we do, and in being an educator. This characteristic is defined as the ability to facilitate patient and family learning. An example that comes to mind regarding this characteristic is patient rounds. I love to do patient rounds on the unit. I do it for two reasons. Number one, I want to get a good feel for what the nursing practice is on the unit that I cover, but also I utilize those times as a teaching opportunity with the staff. Initially it was so interesting, because the staff was very apprehensive to participating in these clinical rounds. During the "rounds," as I call them, I can actually answer their questions as they tell me about their patient. Over time, what they were able to see was that this was a non-confrontational, very-supportive type of situation where they could actually learn some things about those complex patients that they were caring for. I think by educating the staff at the bedside, we've been able to improve the quality of care that we deliver.

So I hope you can see, as advanced practitioners, how we can incorporate these nurse characteristics and truly, without even thinking about it, identify situations that fall within these nurse characteristics. Thank you.

Barbara: As you can tell from the different vantage points of our panelists today and from the presentations, each of them have something very much in common, and that's care for the outcomes of patients and families, identification of the nursing components and they've brought the Synergy Model to life. What started out as a concept and a philosophy was tested and now is actively contributing to the science of nursing. Hopefully you've been able to see that the model contributes to the art of nursing also. I don't want to take any more time preaching to what I hope now is a melodious choir, and allow each of you to have the opportunity to ask any of the panelists questions and broaden your understanding so you can put this to work. I will start with one question that I think is an important one to mention. I asked Bonnie if she had a budget established to help get the work done to get the Synergy Model put into action. Bonnie's answer was...

Bonnie: Not really. We kind of improvise. I mean, we were given a lot of off-unit time, but I have to tell you that's because of my department director. The effort came from the staff.

Barbara: The point with my question and Bonnie's answer is to show that this is advocacy. You know, if you hook onto this, you'll need to be creative and advocate for the issue and go to work with your managers. You'll also have to be able to translate the model to them in understandable terms so that again, they can see how this is going to impact patient and family care. Questions from the audience?

NOTE: Unfortunately, the questions from the audience were not audible on the tape of this discussion. The answers given by the panelists have been included.

Barbara: We strongly encourage you to use the terminology. When the model was first presented, even to Board members and Committee members, we all said, "Uh-oh, the words are too big. Can't do, too many words, too long, can't discuss it." You know what? We can use grown-up words. We can make it visual. Use your case scenarios. As Tam pointed out, if you're using this as part of your shift-to-shift report, and you start integrating the language, you can use these words. Tam and I were in the unit one day and there was a patient that was clinically stable. You know, if you went through the physiologic components for that patient, the patient was clinically stable. We as a nurse manager and a CNS were uneasy about moving that patient from the unit. Now how many times have you been in that situation? Well, you know what term we came up with? Vulnerability. We use the words; You can use these words when you have the patient scenarios in front of you. If you simply take the definitions on paper, it's a lot of words. But that's what the Study of Practice did for us. By applying it to patient scenarios, we can use these words to describe what is happening with our patients. So don't avoid using them, and I encourage you not to substitute terms, because the terminologies have been tested via the Study of Practice. If you start substituting terms, then the science of the model weakens. Other comments? Other questions?

Barbara: If you can teach Martha Rogers, then hats off to you. But that's where things got lost. That's why we all groaned about models and nursing because they were isolated from the real patient and family world that we interacted with day-to-day and that's what made it so hard. I'm not sure that Calista Roy and Dorothea Orum and Martha Rodgers were wrong or very difficult, we just never got them to day-to-day practice.

Barbara: I couldn't agree more. You know, if those nursing scholars hadn't done the work in the development and testing of models, we couldn't continue to develop and test models. They really were the pioneers. We owe them a great deal. Our thinking would never have progressed past sharpening needles, emptying bed pans and cool hands on fevered brows if they hadn't taught us how to develop models and test concepts. We're nearing the end of the session, one last question?

Barbara: Listen to all these good examples. Well, thank you for that. Thanks to each of you for the good work that you're doing with the model. Also, I want to remind you that Martha Curley is editing a column in Critical Care Nurse every month on Synergy. This column will reflect what's going on in practice related to Synergy. Martha, I know that you would like to have these examples for your column. So communicate via the journal to Martha and let her know about these examples and she'll be delighted to integrate them into the ongoing communication about putting the Synergy Model to work. Thank you and enjoy the rest of the NTI.

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