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
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
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
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
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.
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
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
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
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.
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;
2. AACN Certification Corporation.
CCNS Study of Practice. 1998.