The Synergy Model: Building a Clinical Advancement Program

Critical Care Nurse, Vol. 19, No. 4, August 1999

Sandra Czerwinski, RN, MS, Lori Blastic, RN, BSN, CAPA, Bonnie Rice, ARNP, MSN, CCRN

Registered nurses providing direct patient care account for the single largest percentage of the workforce in hospitals and healthcare systems. Experienced nurses are extremely valuable to any healthcare organization, and their numbers are diminishing. Nursing leaders are continually challenged to find innovative solutions that define, recognize, and reward expertise demonstrated at the bedside. Healthcare organizations need bedside nursing expertise now more than ever because increased patient acuity and diminishing resources demand it. At the same time, however, any solution must clearly demonstrate the impact nurses have on patient outcomes while remaining financially predictable and controllable.

Clinical ladder programs were first developed in 1972 to recognize and reward progressive and increasingly effective nursing practice.1 These programs continued to evolve and began to focus on recruitment and retention issues. 2-4 Benner's "Novice to Expert" model, developed in the 1980s, serves as the framework for many current clinical advancement programs. She asserted that when clinical expertise is adequately defined, rewards and recognition for expertise and contributions will be more likely to follow.5

Learning from the Past

The Clinical Advancement Program (CAP) developed at All Children's Hospital in the mid-1980s was in response to the nursing shortage of that decade. ACH is a 216-bed tertiary care pediatric research and healthcare system located in St. Petersburg, Florida. The initial program was unit-based and was used primarily as a recruitment and retention tool to attract and retain nurses at the bedside. Although starting salaries for newly hired staff RNs were regionally competitive, they were significantly lower than salaries offered in other areas of the United States. The intensive care unit program consisted of advancement by acquiring points for activities such as completing various critical care educational courses, obtaining American Heart Association course provider or instructor status, performing charge and education functions, and achieving national certification. Unit-based clinical advancement programs evolved into a single hospital-wide program that provided an opportunity for all nursing staff to earn more money upon completion and maintenance of specific tasks. The nursing contributions to the patient and system were not emphasized or explored in these early programs, nor were behaviors of clinical expertise defined. Table 1 illustrates the requirements for a level 3 nurse in this hospital-wide program, which consisted of 4 levels of practice from novice to expert. These programs were very expensive and difficult to defend in relation to return on investment to the healthcare system as a whole.

Table 1 Career advancement program - clinical track for RN3*
Clinical Pts Leadership Pts Education Pts Research Pts
Bulletin board/poster presentation (must do 2) 5 Committee member, hospital/nursing division 10
10 Critique and present clinical research articles (must do 4) 10
Case presentation (must do 2 presentations) 5 Committee chairperson, hospital/nursing division 10 ACLS instructor 15 Journal club coordinator (must coordinate 3) 10
Chemotherapy certification 10 Committee member, unit-based 5 BLS instructor 15 Journal club participant (must attend 2) 5
Competency development (must develop 2) 5 Committee chairperson, unit-based 10 NRP 5 Nursing research: proposal implementation 10
Discharge/patient care conference (must do 2) 5 Coordinator, community seminar 15 NRP instructor 10 Nursing standard of care/ protocol/ guideline initiation (must initiate 2) 10
Mock code 10 Hospital/community service (30 hrs) 5 PALS 10 Policy and procedure initiation (must initiate 2) 10
National certification 15 Leadership class (12 hrs) 5 PALS instructor 15 Publication: State/local 5
Nursing consultant 10 Mentor (mentor 1 RN) 10 Clinical staff inservice (must do 2) 5 Publication: National 20
Nursing grand rounds 10 Nursing conference presentation 5 College credit (must take 3 hours per semester) 10 QA & I: Create indicator (at least 2) 10
Policy and procedure revision (must revise 2) 5 Peer evaluations (participate in 3) 5 Conference attendance (with unit presentation) 5 QA & I: Data collection (at least 3) 5
Primary nurse (primary nurse for at least 3 patients) 10 Professional nursing organization member 10 Contact hours (36) 10 Unit project -
Nursing standard of care/ protocol/ guideline revision (must revise 2) 5 Professional nursing organization committee chairperson/officer 10 ECG course 5 - -
Unit project - Relief charge (132 hrs) 5 ECG 12-lead course 10 - -
- - Unit goals - ICU course + 10 - -
- - Unit project - Precept/facilitate (132 hrs) 10 - -
- - - - Presentation for contact hours (must be 2-hr presentation) 10 - -
- -
- Teaching checklist/education material (must develop 2) 10 - -
- - - - Teach outreach 5 - -
- - - - Unit project - - -
*The RN3 demonstrates advanced knowledge and skills in the management of nursing care for specific types of patient populations and their families. The RN3 holistically views patient situations, recognizes typical expected events, and modifies plans in response to those events. The RN3 is able to perceive nuances of a situation and make decisions based on recognizing the important attributes and aspects of the situation. The RN3 effectively shares and communicates information to others. The RN3 demonstrates commitment to nursing practice through participation in various aspects of professional activities.
+Cannot be selected if unit requirement

Although there were very positive professional outcomes of the advancement program, both staff and administration recognized that an advancement program without clearly identified behaviors did not necessarily reward clinical expertise or enhance patient outcomes. The philosophical goal of including every nurse had not occurred. Nurses were not being adequately recognized for their daily contributions to patient care and skilled nursing practice. Many expert nurses chose not to apply for advancement because of this issue. In some cases, the nurses who spent time on projects to accumulate points were being advanced and the outstanding clinicians were not. The impact was not measured and the work was not shared throughout the healthcare system so that others might benefit.

A new and more immediate concern was the inconsistent ability to use clinical advancement levels as a method of evenly distributing expertise across staffing schedules and patient assignments. Occasionally nurses at the advanced levels were not always the most appropriate to manage difficult cases or mentor novice staff members. As we examined our current program more carefully, it became clear that we needed to identify differences in clinical behaviors within levels and identify core characteristics of the most expert clinicians. We must define good, better, and best nursing practice. Historically, we bestowed the titles of proficient and expert and gave financial rewards without articulating the clinical behaviors expected from nurses at advanced levels. For the future, we would have to measure patient care outcomes at all levels and consider the organizational impact of the clinical advancement concept as a whole. We had to investigate the worth of clinical advancement from the perspectives of patient and family satisfaction, market share, recruitment and retention cost offsets, cost-benefit analysis, or productivity, turnover, and unexpected time off.

Finally, the CAP was expected to facilitate professional growth and personal feelings of value and worth in the staff nurse. It would be impossible to accomplish these goals without implementing a model that links clinical competencies with patient outcomes.

Searching for a Model

We began our search for an appropriate model by asking nursing staff to identify what characteristics they value in their practice and why they consider certain clinicians to be experts. With this picture in mind, we searched the literature for a model of practices that espoused similar characteristics and values identified by our staff. Models have historically been perceived as barriers to the engagement that occurs among nurses, patients, and families. Many models are abstract and lack the emotional caring component of the profession that was the impetus for many individuals to enter nursing. Our nurses assert that caring about the patients and families is how they define themselves. Unfortunately, caring is difficult to quantify and nursing costs account for a large portion of the healthcare budget. In light of this, nurses must be fluent in the language of cost as well as caring and cognizant of ways to demonstrate their contributions.

The Synergy Model reflects the values and philosophy of professional advancement. 6,7 It describes patient characteristics and nurse competencies and asserts that linking the two will result in optimal patient outcomes. The model is adaptable to all areas of nursing practice, from the primary care provider's office to the operating room. It encompasses the neonatal, pediatric, and adult patient care experiences. The model focuses the patient within a variety of continuums, reflecting not only the holistic and dynamic nature of the patient in a time of physiologic instability, but also recognizing the family and community as essential components in determining a patient's outcome.

Another clear and desirable aspect of the Synergy Model is the definition of 8 nursing competencies. Synergy articulates the wide variety of activities in which nurses are involved every day; many of these competencies reflect the behaviors that our nurses characterized as valuable to nursing practice. The nurse competencies identified in the Synergy Model are described as behaviors on a continuum of expertise that allows us to match behaviors with practice levels and distribute expertise most appropriately. It focuses recognition and reward on clinical practice rather than projects and tasks. It helps shift the focus to nursing's unique contributions to patients and outcomes in all areas affected by nursing practice. This aspect allows the impact of expert nurses to be presented in quantitative and financial parameters that can be understood throughout the healthcare system. The model provides the needed links between clinical competencies and patient outcomes for our clinical advancement program.

The competencies identified in the Synergy Model allow us to categorize the essential behaviors on a continuum from novice to expert. Specifically, clinical judgment behaviors range from practice based simply on policies and procedures to a higher level of practice in which nurses demonstrate the ability to recognize subtle trends and intervene before explicit diagnostic signs are evident. Novices in facilitation of learning behaviors use available learning materials, while expert behavior includes the development, implementation and evaluation of patient educational materials. Collaboration behaviors range from participation in a multidisciplinary team to providing leadership for the team. Response to diversity behaviors range from awareness of cultural differences to incorporating diversity into plans of care. Systems thinking behaviors at the entry level consist simply of knowing other systems within the healthcare system that affect the patients, while experts provide leadership in the delivery of cost-effective care. Advocacy and moral agency behaviors first appear as recognizing the need to advocate for patients and advance to advocating from the family's perspective to develop the plan of care. Clinical inquiry behaviors range from attending educational programs to functioning by changing practice within the system. Caring practices are initially seen as empathetic, compassionate, helpful hands-on care and mature to a full engagement in the family with a focus on "being with," rather than "doing to." The behaviors identified within each of the competency areas have allowed us to identify potential outcomes beginning with the elementary level of safe passage through the advanced levels of quantitative health system impact.

Looking to the Future

We have been synergizing our clinical advancement program for the last 6 months. Most of our work is focused on identifying characteristic behaviors for each competency at each level within the program. Although this has been challenging, our work will result in a description of novice to expert practice at All Children's Hospital based on descriptors articulated by our staff. Table 2 provides an overview of caring practice behaviors we have identified for one dimension of novice and expert nurse practice. These are not just a series of tasks or projects but everyday nursing practices that directly impact the patient's outcome. We have avoided past mistakes by developing a strong outcomes measurement component, including financial indicators, to our program.

Table 2 Career advancement program

Caring practices create a compassionate and therapeutic environment with the aim of promoting comfort and preventing suffering. These nursing activities are responsive to the uniqueness of patients and their families.
Level Performance standards Behavioral characteristics Measurable outcome tools Outcomes assess- ment
Entry level RN I - Engages in basic caring practices focusing on the psycho-social and physiological needs - Provides compassionate, helpful and empathetic hands-on care - Maintains a caring physical environment - Recognizes own feelings relating to patient and family relationships - Maintains patient privacy and confidentiality - Visibly engages with patient/ family (listens, supports) - Allows caregivers to stay with toddler; keeps familiar objects nearby - Develops an understanding of the child's "safe place" - Provides sleeper chairs and linens - Monitors and controls noise levels - Acknowledges death as an outcome - Facilitates family housing (Ronald McDonald House) - Patient/ family satisfaction (eg, comments, letters, service excellence, satisfaction surveys) - Self-evaluation - Performance appraisal - Director evaluation - Peer review - Nurse - Patient - Family
Competent RN II - Tailors caring practices to recognize the individuality of patients and family - Attentive and responsive to subtle physiological, emotional and spiritual needs - Develops professional relationships that facilitate patient/family coping - Engages patient and family in a compassionate manner - Acknowledges different wellness states as potential outcomes - Recognizes death as an acceptable outcome - Engages family in planning and participating in care - Modifies plan of care to optimize inclusion of the family and minimize trauma - Maintains "safe place" for patient (takes patient to treatment room for all stressful procedures) - Encourages and supports parental comfort measures - Prepares family for potential disease trajectory (listens, counsels, provides support group information) - Functions as a primary nurse - Patient/ family satisfaction (eg, comments, letters, service excellence, satisfaction surveys) - Self-evaluation - Performance appraisal - Director evaluation - Peer review - Exemplar - Nurse - Patient - Family
Proficient RN III - Promotes an environment grounded in empathy, kindness, and a deep regard for the individual - Anticipates patient/families emotional and spiritual needs - Recognizes that healing requires more than physical interventions - Acknowledges the impact of illness on the patient/family and acts to alleviate fears - Incorporates family support into the daily plan of care - Establishes trusting, professional relationships with the patient/family and the healthcare team - Interacts with patient/family holistically - Recognizes family dynamics and promotes supportive behaviors - Individualizes caring practices to the needs of the patient and family - Recognizes and incorporates the "little things" that promote comfort and prevent suffering - Explores patient/family comments and perceptions to modify plan of care (smelling food when NPO, events that disturb normal sleep patterns) - Provides empathetic guidance and support - Leads in monitoring quality of practice - Patient/ family satisfaction (eg, comments, letters, service excellence, satisfaction surveys) - Self-evaluation - Performance appraisal - Director evaluation - Peer review - Exemplar - Nurse - Patient - Family - Unit
Expert RN IV - Demonstrates a deep understanding of the unique meaning and impact of health, illness, and disease on the family - Orchestrates the processes that support the patient and family surrounding issues of wellness or death and dying - Helps to promote healing by helping the patient/family cope with fears and concerns - Preserves, protects, and enhances human dignity - Develops methods for measuring positive and negative experiences for creation of hospital improvements - Fully engages with the family focusing on "being with" rather than "doing to" the patient - Uses creative approaches to empower patients and families - Incorporates holistic considerations and alternative therapies in the provision of care - Anticipates hazards and promotes safety throughout the patients and families transition along the health care continuum - Develops and implements plans to encourage caring interventions with dysfunctional or difficult patient/family - Patient/family satisfaction (eg, comments, letters, service excellence, satisfaction surveys) - Self-evaluation - Performance appraisal - Director evaluation - Peer review - Exemplar - Quality assurance/quality improvement (research, ethics, committee) - Nurse - Patient - Family - Unit - Hospital/ system

There was much excitement about the model among staff who were investigating the application to the CAP as practice differentiation and measurement are becoming reality. We are using role playing to apply the Synergy Model to bedside situations and examine nursing's impact on the patient, nurse, and system outcomes. This began a phase of discovery where the brilliance of the concepts became clear to staff first learning about the Synergy Model. Staff could clearly see that what they valued about nursing practice was reflected within the Synergy Model. Although practicing within the framework of a nursing model was new to the staff, they could define themselves within the concepts of the nurse, patient, and outcome components of the Synergy Model. To date, support and enthusiasm for the model and the CAP by our staff have been phenomenal.

Although we still have a significant amount of work to complete, we are confident that the new program will address the numerous contributions of nurses at all skill levels. This project would have been much more difficult without the clarity that the Synergy Model brings to the dynamic aspects of the patient and nurse relationship.


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