Overview of the Theoretical Review Process

Critical Care Nurse, Vol. 20, No. 1, February 2000

Karen R. Sechrist, RN, PhD, Linda E. Berlin, RNC, DrPH, Melissa Biel RN, MSN

Since the development of the Synergy Model by the AACN Certification Corporation, the major tenets of the model have been described, tested in a validation study (Greenberg S, Muenzen PM, Smith IL, unpublished manuscript, 1999) and applied in clinical settings. The next logical step, as identified by the Board of Directors of AACN Certification Corporation, was to obtain critical evaluation of the Synergy Model by an independent panel of reviewers with expertise in nursing theory analysis from varying clinical perspectives. The goal of the review process was to identify the strengths and weaknesses of the Synergy Model and obtain recommendations regarding refinement of the model. The Board of Directors contracted with Berlin Sechrist Associates to develop the review instrument, oversee the entire review process, and summarize the results. The Board of Directors appointed an advisory group to provide input into all aspects of the process. Members of the Synergy Model Advisory Group: Kimmith Jones, RN, MS, CCRN; Aimee Lyons, RN, MSN, PNP, CCRN; Patricia McGaffigan, RN, MS; and Daphne Stannard, RN, PhD. Martha Curley, RN, PhD, CCNS, CCRN joined the group following selection of the reviewers.

As a call for reviewers, all members of the American Academy of Nurses were sent a letter, in which the objective of the review process and the selection criteria were described, accompanied by a reprint of Curley's article, Patient-Nurse Synergy: Optimizing Patients' Outcomes. Respondents were invited to apply or to encourage nonmember colleagues to submit applications. The 84 respondents provided copies of their curricula vitae, along with signed forms indicating willingness to participate and meet the time line obligations. Berlin Sechrist Associates reviewed all credentials and recommended 10 individuals based on the following selection criteria: expertise in analysis of theoretical and conceptual frameworks or models, clinical specialty, and geographic region.

Berlin Sechrist Associates developed a review form that was designed to obtain qualitative and quantitative information. Development of the form was challenging because there is considerable variation with respect both to the terminology and essential components for the evaluation of conceptual frameworks or theory in the literature. Rather than selecting one critique schema, an attempt was made to meld existing terminology and components into criterion categories that would prompt thoughtful responses regardless of the framework preferences of the reviewers.

The review instrument was organized in six major criterion sections: clarity, consistency, adequacy, utility, significance, and summary. Reviewers were asked to respond separately to specific components of each criterion to ensure comprehensiveness of responses (Table). In addition to narrative response, six-point scales were developed to measure quantitative ratings for each of the criterion components. Each rating scale was anchored by the total absence to total presence of the criterion component, such as "unclear" and "very clear" for clarity.

Synergy Model review instrument criteria and criterion components
Criterion Criterion component
Clarity Explanation of the philosophical bases of the Synergy Model (the Model)
Description of the central principle, definitions, and assumptions
Inclusion of the meaningful diagrams and explanations
Logic of presentation
Lack of ambiguity
Clarity overall
Consistency Congruence of the Model with its philosophical bases
Constancy in use of terms, interpretations, and components of the Model
Coherence in concepts of the Model
Consistency overall
Adequacy Comprehensive of scope within area of concern and level of development
Inclusive of concepts related to person, environment, health, and nursing
Reflective of current nursing realities
Adequacy overall
Utility Feasibility of using concepts of the Model to guide nursing practice, education, administration, and research
Applicability of the Model beyond the critical care setting to other clinical, cultural, and geographic settings
Attainability of projected outcomes
Testability of concepts of the Model
Ability of the Model to generate quantitative and qualitative research
Utility overall
Significance Delineation of essential issues in nursing
Derivation of nursing interventions influencing patient outcomes
Development of nursing knowledge
Discrimination of nursing from other health professions
Congruence of the Model with patient, community, and healthcare system expectations
Significance overall
Summary Potential contribution of the Model to nursing as a discipline
Potential of the Model to positively affect patient outcomes
Strengths of the Model
Weaknesses of the Model
Recommendations for refinement of the Model

On September 1, 1999, review materials, including all publications about the Synergy Model, were mailed to reviewers. Nine of the 10 reviewers completed the in-depth review process by November 1; they are Barbara Stevens Barnum, RN, PhD; Marion E. Broome, RN, PhD; Rose E. Constantino, PhD, JD, RN; Jacqueline Fawcett, PhD; Edna M. Menke, PhD, RN; Carolyn Murdaugh, RN, PhD, Patricia Moritz, PhD, RN; Bonnie Rogers, DrPH, COHN-S; and Marilyn Frank-Stromborg, EdD, JD, ANP.

Reviewers' responses and comments were summarized using quantitative and qualitative analytic procedures. The results were discussed with the Synergy Model Advisory Group and presented to the AACN Certification Corporation Board of Directors. Further, results will also be presented at the AACN National Teaching Institute and will be summarized for publication. The results will be used to further guide the refinement of the Synergy Model.


1. Biel M. Reconceptualizing Certified Nursing Practice: Envisioning Critical Care Practice of the Future. Aliso Viejo, Calif.: AACN Certification Corporation; 1997.
2. AACN Certification Corporation. Resource Booklet. Aliso Viejo, Calif.: AACN Certification Corporation; 1997.
3. Curley MAQ. Patient-nurse synergy: optimizing patients' outcomes. Am J Crit Care. 1988;7(1):64-72
4. Edwards DF. The Synergy Model: linking patient needs to nurse competencies. Crit Care Nurse . 1999;19(1):88-90.
5. Moloney-Harmon PA. The Synergy Model: contemporary practice of the clinical nurse specialist. Crit Care Nurse. 1999;13(3):79-82.
6. Small B, Moynihan P. The day the lights went out: one charge nurse's nightmare. Crit Care Nurse. 1999;13(3):79-82.
7. Czerwinski S, Blastic L, Rice B. The Synergy Model: building a clinical advancement program. Crit Care Nurse. 1999;19(4):72-77.
8. Barnum, BS. Nursing Theory: Analysis, Application, Evaluation, 5th ed. Philadelphia, Pa: Lippincott; 1998.
9. Chin PL, Kraemer MK. Theory and Nursing: A Systemmatic Approach. St. Louis, Mo: Mosby-Year Book; 1991.
10. Fawcett J. Analysis and Evaluation of Conceptual Models of Nursing, 3rd ed. Philadelphia, Pa: FA Davis; 1995.
11. Meleis AI. Theoretical Nursing: Development and Progress. 3rd ed. Philadelphia, Pa: Lippincott; 1997.
12 . Silva MC, Sorrell JM. Testing of nursing theory: critique and philosophical expansion. Adv Nurs Sci. 1992; 14(4):12-23.
Your Feedback