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The Synergy Model and the Role of Clinical Nurse Specialists in a Multihospital System

	Abstract

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The role of clinical nurse specialists was formalized in the 1950s; the goal was to prepare inpatient, bedside nurses who would serve acutely ill patients via consultation and direct care. Clinical nurse specialists were to be expert clinicians, consultants, educators, and researchers. In the early stages of practice development, the focus was the specific needs of the assigned unit or floor. Organizational restructuring led to the elimination of many positions for clinical nurse specialists, with a shift of some of the nurses’ responsibilities to others (ie, managers) or the abandonment of some of the traditional roles. Recently, a reversal occurred in this trend, evidenced by a steady growth in the demand for these advanced practice nurses by organizations seeking to improve patients’ outcomes while remaining fiscally responsible. This demand led to changes in role expectations and expanded the responsibilities of clinical nurse specialists to a system-wide or organization-wide level. Contemporary practice of clinical nurse specialists is not well reflected in traditional role definitions or commonly accepted practice models. The Synergy Model, developed by the AACN Certification Corporation, was introduced as a way of linking certified practice to patients’ outcomes. The model describes 8 nurse characteristics and 3 spheres of influence. This article describes how a group of clinical nurse specialists applied the model to successfully change from a unit-based to a multisystem practice.

In many organizations, positions for CNSs were eliminated, with a shift of some responsibilities of these nurses to others (ie, nurse managers) or an abandonment of some of the traditional roles (ie, researcher, educator). Recently, a reversal occurred in this trend, evidenced by a steady growth in the demand for these advanced practice nurses by organizations seeking to improve patients’ outcomes while remaining fiscally responsible. Additionally, the trend of hiring and training recent nursing graduates in specialty areas typically reserved for more experienced practitioners (eg, intensive care unit, operating room) has created a need for intense education and orientation coordinated by CNSs.

These organizational changes have led to modifications in the role of CNSs and have expanded the responsibilities of these nurses to a system-wide or organization-wide level. Nowadays, a CNS is expected to move through multiple units at a single location or various locations, facilitate process changes at a system-wide level, and expand his or her knowledge of specific patients cared for or services offered within the assigned areas. In addition, healthcare organizations and regulatory agencies (eg, the Joint Commission on Accreditation of Healthcare Organizations) increasingly are demanding measurable positive patient outcomes associated with changes in practice that are often CNS driven. Contemporary CNS practice is not well reflected in traditional role definitions or commonly accepted practice models.

The Synergy Model, developed by the AACN Certification Corporation, was introduced as a way of linking certified practice to patients’ outcomes.³ The model describes nurses’ practice on the basis of "the needs and characteristics of patients and the demands of the healthcare environment predicted for the future."² Patients’ characteristics drive the nurses’ competencies, and when the characteristics of a patient and the competencies of a nurse match and synergize, patients’ outcomes are optimized.³ The Synergy Model describes 8 characteristics of nurses (clinical judgment, clinical inquiry, facilitator of learning, collaboration, systems thinking, advocacy/moral agency, caring practices, and response to diversity) and 3 spheres of influence (patient/family, nurse-nurse, and system).⁴

The North Broward Hospital District, Fort Lauderdale, Fla, is a multihospital system in an urban environment. The system, which is the seventh largest not-for-profit healthcare corporation in the United States, consists of 2 trauma centers (744 beds and 409 beds), 2 smaller community hospitals (204 beds and 200 beds), a freestanding ambulatory surgical center, an extensive array of ambulatory centers, and multiple physician-owned practices. The role of CNSs in the system was established by the administrator for patient care services at the largest hospital in the system. She had worked as a CNS in another state and recognized the potential benefit of this advanced practice role in the Florida organization. The nursing specialty areas are represented in our group by a total of 14 CNSs, who are responsible for medical-surgical nursing (4), women and children’s services (4), oncology nursing (1), critical care (2), trauma care (1), perioperative services (1), and emergency services (1). For many years, the traditional unit-based role was followed in our system. However, when the system was restructured, the traditional unit-based CNS role was expanded to a multicenter model. In this article, we describe how the Synergy Model was used to successfully develop the new CNS role and how this model assisted a group of CNSs in determining how to best serve the needs of an organization while continuing to generate positive patients’ outcomes and maintain fiscal responsibility.

	Clinical Inquiry

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With the rapid advances in healthcare knowledge, clinical inquiry is more important than ever before. How can a group of CNSs working in a multicenter system foster enthusiasm for clinical inquiry? In general, clinical inquiry in the form of research has attained a rather "bad name" among bedside nurses. Many nurses have suffered through dry research courses in undergraduate and graduate programs, an experience that decreased their passion for further studies after graduation. Our CNS group thinks that creating an environment in which the pursuit of excellence supports clinical inquiry to improve clinical outcomes⁴ is important in all hospitals within our system.

To foster enthusiasm for research, we used multiple methods. Each CNS read and critiqued a nursing research article and then posted both the article and the critique in areas (eg, staff bathrooms) where staff members would have a few minutes of uninterrupted time to read the material. Staff members commented on some of the research topics posted and discussed some of the related issues with each other and with members of the CNS group. Research critiques written by the CNS group were also published in our district-wide nursing newsletter along with brief articles on research concepts (eg, developing research ideas, applying research at the bedside). These strategies increased understanding of research terminology and interest in research reviews.

Simultaneously, CNSs participated in the development of a clinical ladder with a research component, a development that spurred an increased interest in research activities by staff nurses. However, many staff nurses expressed an inability to meet the research requirements of the ladder and requested assistance from the nursing research committee. Once the interest in clinical nursing research was enhanced, the CNS group developed a user-friendly tool to facilitate the ability of staff members to independently critique articles (see Table). Additionally, CNSs promoted evidence-based practice by presenting formal seminars and by encouraging staff members to attend at least 1 meeting of the nursing research committee.

Each meeting includes a 30-minute presentation on a research topic of interest (eg, institutional review boards, conducting literature searches, components of a research proposal), reviews of research proposals, and reviews of evidence-based practice standards (eg, blood conservation protocol, oral care procedure for intubated patients). Members of the nursing staff participate in nursing research by assisting with research protocols and data collection. Members of the research committee present research critiques at unit-based staff meetings, assist in seminar planning, and conduct nursing research.

The institutional review board is the overseeing and approving committee for all research conducted within our hospital system. CNSs have made a significant contribution to the nursing research community by successfully lobbying to have a representative for clinical nursing on the institutional review board. Previously, clinical nursing was not involved in the research approval process. As a member of the institutional review board, the CNS representative has become a liaison between the board and the nursing research committee.

Members of the nursing research committee and other presenters at the meetings of the institutional review board often described the experience of obtaining approval from the board as rigorous and intimidating. In particular, questions, comments, and recommendations of members of the board were perceived negatively by nurses, particularly by novice researchers. The CNS addressed these concerns with the board and suggested the formation of a subcommittee to provide researchers with clear guidelines and expectations for proposal presentation, particularly components of informed consent. As a result of this subcommittee, the institutional review board provides an informational packet that includes a checklist, a sample proposal, and a sample of an informed consent form to all researchers submitting proposals for review by the board. This improved process provides a positive perception of the process of institutional review and ensures completeness of the submitted proposal.

The CNS group, in collaboration with the nursing research committee, sponsors an annual nursing research symposium as part of our system-wide activities. This forum is used to celebrate colleagues’ scholarly accomplishments by using oral and poster presentations that convey the vital role research plays in clinical practice. In order to assist and encourage nursing staff to "think research" and ask research questions, the symposium has 2 distinct sessions. A back-to-basics session is intended for members of the nursing staff who are new to research or who would like a review of some of the basic principles of reading and conducting research. In the advanced sessions, presenters develop and build on the basic material. The intent of the 2 sessions is to provide information of different complexity to encourage participation in research by staff members who have different comfort levels with doing research.

Research findings are disseminated at a systemwide level through a department of nursing publications. Members of the nursing research committee write a regular column summarizing the details of a clinically relevant study. One aspect of the research process is also explained in each publication.

Evidence-based practice is another component of clinical inquiry.⁵ Within our multifacility system, we encourage evidence-based practice via our policies and procedures. Representatives from all 4 hospitals serve on the standards committee, including CNSs from various areas. Information related to evidence-based practice and practical "how-tos" for performing a literature search are provided at the initial annual meeting of the standards committee. A CNS provides examples of current research that may provide a framework for changes in practice. The assigned standards committee member presents all literature sources and rationales at the standards review committee meeting. To encourage involvement by staff members in the development of standards, members of the standards committee encourage nursing staff to continually ask, Why are we doing things this way? On the basis of the evidence presented, current standards of care, and available equipment, members of the standards committee approve or disapprove suggested revisions of current standards.

Evidence-based practice is used in our system in 2 different ways: by incorporating research findings from published literature and by incorporating findings from research conducted at our facilities into clinical practice. Recent literature and attendance at a lecture at a national conference prompted the CNS from critical care to investigate the development of a protocol for oral care for patients. The literature indicated that the highest rate of ventilator-associated pneumonia was related to inadequate oral care.⁶ Further evidence of the need for standardization of a protocol for patients’ oral care was provided during participation in a national study on suctioning techniques and airway management practices. Data revealed a nationwide inconsistency in oral care practices and validated the need for a multi-disciplinary protocol. To participate in this national research study and implement the resulting protocol, the CNS collaborated with the respiratory therapy service, material management service, and outside vendors. Because of this protocol, patients now receive consistent oral care from all their care providers.

Published literature often sparks inquiry in our setting. Prompted by recent literature, the perioperative CNS investigated the occurrence of inadvertent perioperative hypothermia in surgical patients.⁷ After analysis of the data, intense education on the etiology, physiological response, and recommended nursing interventions to prevent perioperative hypothermia was provided to all staff on the surgical services (preoperative, operating room, postanesthesia care, and anesthesia personnel). A multidisciplinary team, chaired by the CNS, was convened to develop a protocol to prevent inadvertent perioperative hypothermia. Results have been encouraging. Before implementation of the protocol, the prevalence of postoperative hypothermia was 25%. Six months after implementation, the number of patients who became hypothermic had decreased by 12%.

	Facilitator of Learning

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As educational needs are recognized, the CNS group determines if the needs are related to a specific unit or are more global, spanning the hospital or several hospitals in our system. Some educational needs are best handled on a small scale, such as an individual care unit, whereas others require a larger forum such as a seminar.

Nursing grand rounds are another mechanism for providing information and education. Each of the 4 medical centers sponsors this monthly event in which members of the nursing staff are responsible for planning and presenting an interesting case. During the presentation, staff members review current literature pertinent to the care of the patient whose case they are presenting and the patient’s history, assessment, interventions, plan, and outcome. CNSs often facilitate use of resources for the literature search and assist in developing audiovisual aids; however, staff members are responsible for presenting the case.

By highlighting a specific patient and the patient’s family, professional staff are able to address the holistic and personal aspects of the staff ’s nursing care. Nursing grand rounds allow individual departments to showcase what staff members do best: care for people. Furthermore, in preparing for their talk and as a byproduct of the review of current literature, staff members have the opportunity to ensure that nursing care is congruent with best practices.

One example in which the literature search led to improvement in nursing care was the presentation of a case study of a law enforcement officer admitted to our trauma resuscitation unit who had blunt thoracic trauma that caused a pseudoaneurysm of the descending thoracic aorta. While researching the literature related to pseudoaneurysm, staff members discovered that a systolic blood pressure higher than 90 mm Hg is associated with increased mortality.⁸ As a result of the literature search and case review, staff now provide improved care to patients with pseudoaneurysm.

Because of the varied skills and talents of the CNS group, a wealth of programs are available to facilitate learning within our multihospital system. Training courses are offered for many nursing specialties, including emergency care, critical care, maternal-child health, perioperative nursing, trauma care, and oncology nursing. These formal training courses are ongoing and are scheduled in response to vacancy rates in the different clinical areas. Staff members always have an opportunity for professional growth. With 4 hospitals, a surgicenter, and several ambulatory centers to choose from, there is seldom a chance that a staff nurse would become stagnant in one area of nursing for lack of clinical challenge.

	Clinical Judgment

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In collaboration with the nursing staff, respiratory therapy personnel, medical staff, epidemiology staff, nutritional services staff, physical therapy personnel, and case management staff, the CNS group participates in multidisciplinary rounds on selected groups of patients with complex conditions. Trauma rounds are done weekly to review the progress of all in-house trauma patients from resuscitation through rehabilitation. On ventilator weaning rounds, the care of patients receiving mechanical ventilation who require complex weaning strategies is reviewed. Discharge rounds are done for in-house patients with complicated discharge planning needs.

By participating in rounds, CNSs support the nursing staff ’s clinical judgment and act as mentors by sharing knowledge and experience in the care of patients with complex conditions. Specifically, the care plans of individual patients may be discussed and modified on the basis of the patients’ responses to nursing intervention. The CNSs provide expertise encompassing research, critical thinking, collaboration, resource acquisition, education, and review of the plan of care.

Recently, both the critical care CNS and the trauma CNS participated in rounds on a critically injured adult trauma patient. Injuries included massive pulmonary contusions and smoke inhalation. The patient was in acute respiratory distress with ventilation-perfusion mismatching. Traditional methods to reduce the mismatch were unsuccessful. The two CNSs proposed prone positioning as a treatment option for the patient’s injury. Collaboration was required between medicine, nursing, and respiratory therapy staff to implement the plan of care and determine an outcome measurement that would validate the success of treatment. Concomitant injuries prevented routine prone positioning of the patient, and staff asked for guidance in solving the logistics and understanding the physiological endpoints to be measured. Turning to the literature, the CNSs in collaboration with respiratory therapy and medical staff determined that the recommended outcome measure was the alveolar-arterial difference in oxygen. In addition, the CNSs supported staff nurses by developing a time schedule and came in to assist the nurses with placing the patient in the prone position.

Individual CNSs also make frequent patient care rounds in clinical areas or may be consulted on specific patient care needs. The presence of a CNS often triggers questions from staff related to nursing process or skills needed in the care of a specific patient. The presence of a clinical expert, who is not in a management capacity, encourages open discussion and curiosity by professional staff related to evidence-based practice and new trends in patients’ care.

	Collaboration

Top Abstract Clinical Inquiry Facilitator of Learning Clinical Judgment Collaboration Systems Thinking Advocacy/Moral Agency and Caring... Response to Diversity Conclusion References

 
Although the CNS group is divided by service responsibilities (eg, surgery, trauma, critical care, medical-surgical, oncology), we are successful in initiatives involving large units, multiple departments, entire medical centers, or the hospital system only in so far as we are able to collaborate. Collaboration, the ability to work with others to achieve a common goal, is essential for advanced practice nurses to bring change or improvements to complex systems.⁹ The old adage that "no man is an island" suits our experiences well.

Furthermore, collaboration crosses the boundaries of most components of the Synergy Model, most notably, clinical judgment, facilitator of learning, systems thinking, and caring practices. In other words, collaboration supports and enhances everything that we do.

The critical care CNS facilitated a multidisciplinary task force composed of physicians, anesthesiologists, and respiratory and pharmacy personnel to resolve problems regarding the lack of available medications during emergency airway management procedures. The lack of neuromuscular blocking agents, controlled medications, and specialized airway devices on the resuscitation cart was identified as the cause of delays in definitive emergency airway management at resuscitation events. Obstacles including refrigeration of medications, regulatory standards, and the expense of needed equipment prevented easy resolution of these issues. Having a collaborative physician-CNS relationship allowed all parties to state their needs and resolve the problem.

Our unifying goal is to improve the practice of clinical nursing within our system, thereby enhancing positive outcomes for patients and the experience of our clients. Collaboration involves both intragroup and intergroup systems. We often work with healthcare providers from other disciplines (eg, physicians, pharmacists, dietitians) to meet our shared goals that include planning, implementing, and evaluating programs.

CNS collaboration often leads to multiple conferences, seminars, and nurse internships planned and executed by the entire CNS group or by a select subset based on the expertise of the individual CNS. Conference topics are selected on the basis of staff needs assessments, clinical issues identified during rounds, literature review, best practices used outside our hospital district, risk management, and performance improvement trends. Some examples of this collaboration are forensics seminars conducted jointly by the trauma CNS and the perioperative CNS; a seminar on bedside emergencies developed collaboratively by medical-surgical CNSs with lectures provided by the emergency department CNS, the trauma CNS, and the critical care CNS; labor and delivery nurse internship programs with the surgical component taught by the perioperative CNS; and critical care nurse internship programs taught by many members of the CNS group.

In response to new requirements of the Joint Commission on Accreditation of Healthcare Organizations for pain management, a collaborative multidisciplinary team was formed that included several CNSs. This collaboration has been an ongoing project involving research (eg, surveys, quality assurance), education (eg, lectures, subject matter experts), practice reviews, and practice changes (eg, assessment and response modifications to patients’ subjective experiences).

In a large, multicenter system such as ours, it is important that lines of communication between individual CNSs remain fluid. Often weeks pass without seeing certain members of the group. As a group, we meet monthly to network, solve problems, generate ideas, ensure that projects remain on target, and support one another. An annual strategic planning session is held off site to coordinate projects and educational offerings and avoid duplication of CNS effort. Additionally, the role of advanced practice nurses is one that is often poorly understood by the healthcare community and is difficult to justify. During strategic planning sessions, the CNS group, through collaboration with administration and other healthcare professionals, is able to effect change within the system, thereby meeting our goals of improving the practice of clinical nursing, enhancing positive outcomes for patients and the experience of our clients, and showing that the role of CNSs is valuable.

	Systems Thinking

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Our environment is a complex system that has grown to include 4 medical centers, multiple ambulatory centers, and physician-owned practices. Success in this environment requires a thorough understanding of systems theory. One of the most successful projects that illustrates systems thinking is the standardization of all nursing policies and procedures in our medical centers. In order to accomplish standardization, a system-wide committee led by a CNS was established with representatives from each medical center. Over time, this group standardized all policies and now reviews and revises policies annually or as necessary.

Systems thinking and collaboration are intimately linked. Many of the broad-scale initiatives undertaken by the CNS group have involved collaboration across disciplines. Most recently, our hospital system converted to a "powder-free" environment (the elimination of cornstarch glove powder) in all patient care areas. The perioperative CNS recognized that meeting the needs of patients who are sensitive or allergic to latex posed challenges for nursing staff. Shortly thereafter, it was realized that the issues associated with allergy or sensitivity to latex extended beyond the realm of patients’ care, potentially affecting the health of both employees and physicians.^{1 0} In order to explore the issues, a latex allergy task force was formed. This multidisciplinary group, chaired by the perioperative CNS, included representatives from all 4 hospitals in the system. The group consisted of staff nurses, nurse managers, administrators, CNSs, physicians, employee health personnel, risk management staff, materials management personnel, facilities management staff, and human resources personnel.

The first task of the group was review of the literature and self-education. Additionally, a subject matter expert was brought in to present current research. Last, an industry representative did a financial impact study. This study provided an estimate of the current state of affairs across the system and presented a fiscal worst-case scenario should our experience with sensitivity or allergy to latex mirror the experience nationwide. As a result, the latex allergy task force, with a strong endorsement from the administration, made the decision to remove all powdered gloves from our environment.

The conversion was a 2-tiered process that began with elimination of powdered, unsterile gloves. This change produced an annual saving of approximately $86 000. Because the performance characteristics of sterile gloves are more user defined, the second tier of the project involved the planning and implementation of a clinical product evaluation. Once a final product was selected, conversion was implemented systemwide during a 4-week period. The perioperative CNS was intimately involved with all aspects of the project. The success of the project depended on having the CNS facilitate frequent communication, education, research, and physicians’ participation.

	Advocacy/Moral Agency and Caring Practices

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The role of CNSs as advocates for staff nurses and patients is best illustrated by role modeling. Moral, ethical, and professional obligations inherent in the role of a CNS may conflict with personal convictions. Often, a CNS acts as the moral agent when advocacy for a patient or staff member is required.

Case Study
Mr F., a 45-year-old man involved in a head-on motor vehicle crash, was admitted to our surgical-trauma intensive care unit with a C3-C4 subluxation that paralyzed him and necessitated mechanical ventilation. His hemodynamic condition was stable by day 2, and he was awake, alert, and able to communicate by using repetitive eye blinks. In his living will, Mr F. stated that he would choose to withdraw life support rather than be permanently dependent on a ventilator. Frequent communication with his family revealed that he desired to have ventilator support withdrawn.

The intensive care unit called on the CNS to coordinate Mr F.’s plan of care. First, the CNS verified that Mr F. was permanently paralyzed and ventilator dependent. Then she spoke with Mr F. and his family and confirmed the validity of his advanced directive. She spent time with him and his family discussing the impact of his expressed wishes, including that cessation of mechanical ventilation would lead to his death. Mr F. and his family verified their understanding of the information presented and reaffirmed that he did not want to be dependent on mechanical ventilation, even if death was the alternative.

To comply with written policies, Mr F. had to be deemed competent by 2 independent psychiatrists. The CNS requested that the ethics team review the case and make a recommendation. Some members of the healthcare team could not morally support Mr F.’s wishes, and they voluntarily removed themselves from his care. Nurses spent hours talking to Mr F. during that time; his decision to stop mechanical ventilation never wavered. Members of the hospital’s legal team were contacted to review the case and ensure that both Mr F.’s and the organization’s best interests were protected.

Once the consultations were completed, the CNS arranged a conference that included Mr F.’s family and the primary members of the healthcare team. The ethics team agreed that cessation of mechanical ventilation was a morally sound decision and that maintaining ventilatory support violated Mr F.’s human right to self-determination. The legal team determined that withdrawing life support in this instance was congruent with the parameters of the Patient Self-Determination Act. Additionally, we were cautioned that to ignore Mr F.’s expressed wishes could be considered battery. Last, the independent psychiatrists determined that Mr F. was competent.

With Mr F.’s family and the healthcare team, the CNS planned withdrawal from mechanical ventilation. A principal goal of the team was to preserve human dignity during the withdrawal. A detailed, written care plan was developed that addressed weaning, pain management, anxiety, and support of Mr F.’s family. Mr F. and his family were encouraged to spend time together and to inform the team when they were ready to proceed.

The CNS acted as an advocate for Mr F. by supporting his right to self-determination while assisting with the resolution of the moral dilemma that withdrawal from mechanical ventilation represented for some members of the healthcare team. While caring for Mr F., the CNS demonstrated advanced practice skills of critical thinking while advocating for both Mr F. and members of the healthcare team. The CNS modeled holistic practice while considering the 3 spheres of influence within the synergy model: patient/family, nurse-nurse, and system (potential legal implications to the organization).⁴ Despite the divergent perspectives of Mr F.’s case, the CNS guided the healthcare team so that the focus remained on the compassionate and professional care of Mr F. and his family.

Mentoring of staff was evident throughout the care of Mr F. and his family. The healthcare team was mentored by the CNS in developing and implementing Mr F.’s plan of care, supporting and coping with family dynamics, and identifying and addressing legal and ethical principles. Synergy was achieved as the competencies of the healthcare team were modified to meet the needs and characteristics of Mr. F. and his family, optimizing the clinical outcome.⁴

	Response to Diversity

Top Abstract Clinical Inquiry Facilitator of Learning Clinical Judgment Collaboration Systems Thinking Advocacy/Moral Agency and Caring... Response to Diversity Conclusion References

 
The diversity of the population of patients served by our hospital system may pose a challenge to some persons. Because we are in one of the most popular vacation destinations in the United States, we have a continual influx of tourists and of persons relocating to the area. The mild winters, warm summers, and year-round ocean and outdoor access attract a diverse group. The members of each population demand unique ethnic, cultural, religious, and healthcare considerations to meet their needs. The populations include old and very old persons, immigrants from the Caribbean Islands, Canadians, South Americans, and Asian and Pacific Islanders. South Florida also has a large gay and lesbian population with unique healthcare needs and considerations. To some, this diversity may appear to be overwhelming, but members of our CNS group represent several of these cultures, lifestyles, and ethnic backgrounds. We view this diversity not as challenging but rather as rewarding and normal throughout our day-to-day responsibilities.

Synergy is demonstrated through many of the system-wide processes implemented within our hospital system. For example, our pain management committee recognized cultural, ethnic, and age diversity as a critical aspect in the development of pain-rating tools. Our pain-rating tools are printed in three languages—English, Spanish, and Creole—and in extralarge type for patients with sight impairments. In order to accommodate preverbal children, neonates, and nonverbal adults, various reliable and valid tools to assess these special populations are available. For the treatment of patients with pain, allopathic and complementary modalities are incorporated into policies and procedures implemented system-wide. All members of the healthcare team—medical, nursing, and allied health—are educated in the use of the pain-rating tools. Emphasis on cultural sensitivity and the importance of assessing the needs of each patient and his or her family were emphasized during educational sessions.

	Conclusion

Top Abstract Clinical Inquiry Facilitator of Learning Clinical Judgment Collaboration Systems Thinking Advocacy/Moral Agency and Caring... Response to Diversity Conclusion References

 
Our CNS group has found that the Synergy Model can be used to accurately describe the transition from the traditional unit-based practice of CNSs to a contemporary multisystem practice.¹¹ The key to our success has been the ability to communicate and collaborate with each other to influence the practice of each CNS, with better outcomes for patients and changes across the system.

	ACKNOWLEDGMENTS

 
All work was performed within the North Broward Hospital District.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.

	REFERENCES

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