Pa OBJECTIVES Based on the content in this chapter, the reader should be able to: The Concept of Holism Applied to Critical Care Nursing Practice Critical Care Nursing Practice 1. Describe the value of certification in critical care nursing. 2 Describe the value of evidence-based practice (EBP) in caring for critically il patients. 3 List the six standards for a healthy work environment and describe how the work environment can affect patient outcomes and employee well-being, 4 Describe the critical care nurse's role in promoting a healthy work environment. 5 Explain the underlying premises of the syneray model, Cie care nurses routinely care for patients with complex, life-threatening conditions. In addi- tion to managing the physiological alterations brought on by critical illness, critical care nurses must also manage the accompanying psychosocial challenges and ethical conflicts that often arise in the critical care setting. While operating within a highly technological environment, critical care nurses are charged with providing compassionate, patient- and family-focused care. The overreaching professional goal for the critical care nurse is to promote optimal outcomes for the patients and families who are being cared for in the complex setting of the critical care unit. Becoming certified in the discipline of critical care nursing, seeking to provide interventions that are based on current evidence, working to create and promote a healthy work environment (HWE), and working to cultivate core nursing competencies (eg, clinical judgment, advocacy, collaboration) are strategies the critical care nurse can use to achieve this goal, Value of Certification Specialty certification by the American Association of Critical-Care Nurses (AACN) promotes excel- ence in the critical care nursing profession by helping nurses achieve and maintain an up-to-date knowledge base and allowing nurses to voluntarily 12 TANT INE The Concept of Holism Applied to Critical Care Nursing demonstrate their breadth and depth of knowledge of the discipline of critical care nursing.' Certification has value for patients and families, employers, and nurses themselves: * Value to the patient and family. Certification validates to patients and families that the nurses caring for them have demonstrated experience and knowledge that exceeds that which is assessed in entry-level licensure examinations.’ Experience and knowledge enable nurses to recognize and respond to clinical situations more quickly, and research has shown that nurses who have had their knowledge validated through a certification examination make decisions with greater conli- dence, promoting optimal outcomes.' In addition, nurses who are certified in a specialty have dem- onstrated commitment to continual learning, an attribute that is needed to care for patients with complex multisystem problems + Value to employers. Certification validates to employers that the nurse is committed to the disci- pline and has the knowledge and experience to work efficiently to promote optimal patient outcomes. It hhas been suggested that organizations that support and recognize the value of certification may expe- rience decreased turnover and improved retention rates. In addition, employing nurses who have achieved certification demonstrates to the public (ie, healthcare consumers) and to credentialing organi zations (eg, the Joint Commission, the American Nurses Credentialing Center) that the facility has recruited and retained knowledge-validated nurses." + Value to nurses. Certification provides nurses with a sense of professional pride and achievement, and. the confidence that comes with certification ‘may give the nurse a competitive edge when seeking a promotion or new career opportunities. In addition, certified nurses can anticipate increased recogni- tion from peers and employers. Certification may have monetary benefits as well. For example, some employers recognize certification with a salary dif- ferential, and one of the world’s largest insurance brokers offers a discount on malpractice premiums to nurses who are certified in critical care.’ Evidence-Based Practice in Critical Care Nursing Evidence-based practice (EBP) is the use of the best available research data from well-designed studies coupled with experiential knowledge and character- istics, values, and patient preferences in clinical prac- tice to support clinical decision making.’ The use of research findings in clinical practice is essential to promote optimal outcomes and to ensure that nurs- ing practice is effective." Practice based on intuition or information that does not have a scientific basis is not in the best interest of patients and families. Although knowledge regarding effectual nurs- ing interventions continues to increase, transfer of ractice evidenceinto practice can bea long process. Common barriers to implementation are summarized in Box 1-1, Strategies for promoting the incorporation of evidence into clinical practice include + Useof protocols, clinical pathways, and algorithms* “Increasing clinicians’ awareness of available resources (¢g, databases such as PubMed, CINAHL, and MEDLINE; Web sites such as UpToDate, which, offers real-time evidence-based recommendations, for patient care, and the Cochrane Library, a source of high-quality, independent evidence to inform healthcare decision making; and professional nurs- ing organizations, such as the AACN, which pub- lishes research-based Practice Alerts) Creating an organizational culture that supports, EBP (eg, identifying EBP champions, incorporat- ing EBP activities into nurses’ roles, allocating time and money to the process, promoting multi- disciplinary collaboration among researchers and practitioners)* Healthy Work Environments A healthy work environment (HWE) optimizes pro- fessional collaboration and nursing practice (thus facilitating quality clinical outcomes) and promotes employee satisfaction. In 2001, in light of data indi- ting that harmful healthcare working environ- ments exist nationwide and that these environments result in medical errors, poor healthcare delivery, and dissatisfaction among healthcare providers, the AACN helped develop the HWE initiative. The HWE initiative focuses on barriers to patient safety and employee satisfaction and identifies six essential standards for promoting a HWE: skilled communi- cation, truc collaboration, effective decision mak- ing, appropriate stalfing, meaningful recognition, and authentic leadership (Box 1-2) Skilled Communication Skilled communication is essential to prevent errors as well as to recruit and retain healthcare providers. Almost 70% of sentinel events reported to the Joint Commission in 2005 were related to communica tion issues.’ AACN partnered with VitalSmarts (a [HOW 1-1 wanire to evidence-Bated Practice (EBP) ‘Lack of knowledge ‘+ Lack of research skills, resources, or both ‘Lack of organizational support and management commitment *Lack of time + Lack of incentive to change behavior * Lack of confidence in personal ability to change practice + Lack of authority to change practice[HOWET= critica ctements ofthe six Eason ‘Standard 1: Skilled Communication ‘Nurses must be as proficient in communication skills as they are in clinical skills. "The healthcare organization provides team members with support for and access to education programs that develop critical communication skills including self-awareness, inguiryldialogue, conflict manage- ‘ment, negotiation, advocacy, and listening, + Skilled communicators focus on finding solutions and. achieving desirable outcomes. + Skilled communicators seek to protect and advance collaborative relationships among colleagues. + Skilled communicators invite and hear all relevant perspectives. + Skilled communicators call on goodwill and mutual respect to build consensus and arrive at common. understanding, + Skilled communicators demonstrate congruence between words and actions, holding others account- able for doing the same. The healthcare organization establishes zero-tolerance policies and enforces them to address and eliminate abuse and disrespectful behavior in the workplace, «The healthcare organization establishes formal structures and processes that ensure effective information sharing among patients, families, and the healthcare team. + Skilled communicators have access to appropriate com- munication technologies and are proficient in their use. ‘The healthcare organization establishes systems that require individuals and teams to formally evaluate the impact of communication on clinical, financial, and work environment outcomes, * The healthcare organization includes communica- tion as a criterion in its formal performance appraisal system, and team members demonstrate skilled com- ‘munication to qualify for professional advancement, Standard 2: True Collaboration ‘Nurses must be relentless in pursuing and fostering ‘rue collaboration. "The healthcare organization provides team members ‘with support for and access to education programs that develop collaboration skills ‘The healthcare organization creates, uses, and evaluates processes that define each team member's accountability for collaboration and how unwilling. ness to collaborate will be addressed. ‘+The healthcare organization creates, uses, and evalu- ates operational structures that ensure the decision- ‘making authority of nurses is acknowledged and incorporated as the norm. The healthcare organization ensures unrestricted access to structured forums, such as ethics commi tees, and makes available the time needed to resolve disputes among all critical participants, including patients, families, and the healthcare team. + Every team member embraces true collaboration as; an ongoing process and invests in its development to censure a sustained culture of collaboration. Critical Care Nursing Practice CHAPTE0 1 I Standards of a Healthy Work Environment + Every team member contributes to the achievement of common goals by giving power and respect to each person's voice, integrating individual differences, resolving competing interests, and safeguarding the essential contribution each must make in order to achieve optimal outcomes. + Every team member acts with a high level of personal integrity. ‘+ Team members master skilled communication, an essential clement of true collaboration, ‘+ Each team member demonstrates competence appro- priate to his or her role and responsibilities. + Nurse managers and medical directors are equal part ners in modeling and fostering true collaboration. ‘Standard 3: Effective Decision Making Nurses must be valued and committed partners in ‘making policy, directing and evaluating clinical car, and leading organizational operations. "The healthcare organization provides team members ‘with support for and access to ongoing education and development programs focusing on strategies that censure collaborative decision making. Program con- tent includes mutual goal setting, negotiation, facili- tation, conflict management, systems thinking, and performance improvement, + The healthcare organization clearly articulates organi- zational values, and team members incorporate these values when making decisions, * The healthcare organization has operational struc- tures in place that ensure the perspectives of patients and their families are incorporated into every decision allecting patient care. ‘Individual team members share accountability for effective decision making by acquiring necessary skills, ‘mastering relevant content, assessing situations accu- rately, sharing fact-based information, communicating professional opinions clearly, and inquiring actively. * The healthcare organization establishes systems, such as structured forums involving all departments and. healthcare disciplines, to facilitate data-driven decisions. * The healthcare organization establishes deliberate decision-making processes that ensure respect for the rights of every individual, incorporate all key perspec- tives, and designate clear accountability. *‘The healthcare organization has fair and effective processes in place at all levels to objectively evaluate the results of decisions, including delayed decisions and indecision, ‘Standard 4: Appropriate Staffing Staffing must ensure the effective match between patient needs and nurse competencies. * The healtheare organization has stalling pe place that are solidly grounded in ethical principles and support the professional obligation of nurses to provide high-quality care. (comtinued on page 4) 34 PAUT IME The Concept of Holism Applied to Critical Care Nursing Practice [FOV 1-2 critical Elements of the Six Essential Standards of a Healthy Work Environment (continued ‘+ Nurses participate in all organizational phases of the staffing process from education and planning—includ- ‘ng matching nurses’ competencies with patients’ assessed needs—through evaluation. The healthcare organization has formal processes in place to evaluate the effect of staffing decisions on patient and system outcomes. This evaluation includes analysis of when patient needs and nurse competen- cies are mismatched and how often contingency plans are implemented. ‘The healthcare organization has a system in place that facilitates team members’ use of stalling and out- comes data to develop more efective stalling models. «The healthcare organization provides support services at every level of activity to ensure nurses can optimally focus on the priorities and requirements of patient and family care, +The healthcare organization adopts technologies that increase the effectiveness of nursing care delivery. [Nurses are engaged in the selection, adaptation, and evaluation of these technologies. ‘Standard 5: Meaningful Recognition Nurses must be recognized and must recognize oth- ers for the value each brings to the work of the organization. «The healthcare organization has a comprehensive system in place that includes formal processes and structured forums that ensure a sustainable focus ‘on recognizing all team members for their contri- butions and the value they bring to the work of the organization, +The healthcare organization establishes a systematic process for all team members to learn about the facil- ity's recognition system and how to participate by recognizing the contributions of colleagues and the value they bring to the organization, ‘+The healthcare organization's recognition system reaches from the bedside to the board table, ensuring. individuals receive recognition consistent with their personal definition of meaning, fulfillment, develop- ment, and advancement at every stage of their proles- sional career. # The healthcare organization's recognition system includes processes that validate that recognition is, ‘meaningful to those being acknowledged. ‘*'Team members understand that everyone is respor sible for playing an active role in the organization's recognition program and meaningfully recognizing contributions, *'The healthcare organization regularly and compre- hensively evaluates its recognition system, ensuring cffective programs that help to move the organization toward a sustainable culture of excellence that values ‘meaningful recognition, ‘Standard 6: Authentic Leadership ‘Nurse leaders must fully embrace the imperative of a healthy work environment (HWE), authentically live it, ‘and engage others in its achievement * The healthcare organization provides support for and access to educational programs to ensure that nurse leaders develop and enhance knowledge and abilities in skilled communication, effective decision making, true collaboration, meaningful recognition, and ensur- ing resources to achieve appropriate stafling. ‘Nurse leaders demonstrate an understanding of the requirements and dynamies at the point of care and ‘within this context successfully translate the vision of alHWE, + Nurse leaders excel at generating visible enthusiasm. for achieving the standards that create and sustain HWEs + Nurse leaders lead the design of systems necessary to effectively implement and sustain standards for HWEs, #'The healtheare organization ensures that nurse leaders are appropriately positioned in their pivotal role in ere- ating and sustaining HWEs. This includes participation in key decision-making forums, access to essential infor ‘mation, and the authority to make necessary decisions. * The healthcare organization facilitates the efforts of nurse leaders to create and sustain a HWE by pro- viding the necessary time and financial and human # The healthcare organization provides a formal comen- toring program for all nurse leaders. Nurse leaders actively engage in the comentoring program. ‘Nurse leaders role-model skilled communication, true collaboration, effective decision making, meaningful recognition, and authentic leadership. The healthcare organization includes the leadership contribution to creating and sustaining a HWE as a criterion in each nurse leader’s performance appraisal. Nurse leaders must demonstrate sustained leadership in creating and sustaining a HWE to achieve profes- sional advancement. ‘Nurse leaders and team members mutually and objec tively evaluate the impact of leadership processes and decisions on the organization's progress toward creat- {ng and sustaining a HWE. Prom hutp:/hwww.aacn orglaacnipubpoley.nsPPilesPxecSuanSfieExecSum pdf company that provides corporate training and orga- nizational performance solutions) to conduct a study of conversations that do not occur in hospitals, to the detriment of patient safety and provider well-being, The “Silence Kills” study used focus groups, inter- views, workplace observation, and surveys of nurses, physicians, and administrators in urban, rural, and suburban ‘hospitals nationwide. Overwhelming data indicated that poor communication and col- laboration were prevalent among healthcare provid- ers. The study concluded that healthcare providers repeatedly observe errors, breaking of rules, anddangerous levels of incompetence, yet rather than speak up, they consider leaving their respective units because of their concerns, The ability to communi- cate effectively and assertively and manage conflict is essential for advocating for oneself and others, and fosters a positive workplace environment character- ized by an atmosphere of respect and collaboration. True Collaboration Collaboration is a multifaceted concept, which has been defined as working together to accomplish a common goal. One researcher has identified collab- oration as both a process (blending different points of view to better comprehend a difficult issue) and an outcome (the integration of solutions contrib- uted by more than one person).’ This researcher has identified 10 lessons in collaboration: (1) know thyself; (2) learn to value and manage diversity; 3) develop constructive conflict resolution skills; (4) create win-win situations; (5) master interpersonal and process skills; (6) recognize that collabora- tion is a journey; (7) leverage all multidisciplinary forums; (8) appreciate that collaboration can occur spontaneously; (9) balance autonomy and unity in collaborative relationships; and (10) remember that collaboration is not required for all decisions,” Other investigators have suggested that collaboration is, defined through five concepts: sharing, partnership, power, interdependency, and process." Results of several studies have supported a high correlation between nurse-physician collaboration and positive patient outcomes and a decreased inci- dence of medication errors.” However, a number of barriers exist that preclude true collaboration in healthcare organizations, including variations in how “collaboration” is conceptualized; the lack of time for communication; the complexity of the skills required to facilitate collaboration; and issues related to autonomy, power, and role confusion.” Effective Decision Making Because the healthcare environment mandates that nurses be accountable for their practice, they must be able to participate in effective decision mak- ing. A high degree of responsibility and autonomy is necessary. An environment that consistently and successfully encourages nurses to participate in decision making promotes quality patient outcomes and improved employce satisfaction, Appropriate Staffing There is a significant relationship between inad- equate nurse staffing and adverse patient events. According to the Joint Commission, based on data- base records from 1995 to 2004, staffing levels were a root cause of nearly a quarter of the sentinel events that resulted in death, injury, or permanent loss of function.’ Adequacy of staffing has tradition- ally been based primarily on the number of staff Critical Care Nursing Practice tIAPTER1 5 assigned to a unit on a given shift. However, appro- priate staffing must also consider the competencies of the staff assigned in relation to the needs of the patient and family during that shift. When the needs of patients and families are matched with the com- petencies of the assigned nurse, optimal outcomes may be achieved. The ability to monitor patient health status, perform therapeutic interventions, integrate patient care to avoid healthcare gaps, and promote optimal patient outcomes is compromised when the number of nurses is inadequate, or when nurses lack the required competencies. Meaningful Recognition Employee recognition can have a_ significant effect on job satisfaction, and can help to retain high-performing nurses and ensure an adequate workforce in the future. Effective recognition pro- grams enhance the nurse's sense of accomplishment and validate the nurse's contributions to quality healthcare. The recognition may be modest in scale but must represent genuine caring and apprecia- tion. In addition to monetary rewards when pos- sible, recognition can take the form of verbal or written praise, appreciation, and acknowledgment of excellent performance.'" Researchers have also suggested that to recruit and retain staff, employers need to recognize staff expectations (eg, the desire to lead balanced lives, receive opportunities for per- sonal and professional growth, or make a meaning- ful contribution to the world through work). Authentic Leadership ‘Nursing leaders play an essential role in creating a healthcare environment that is conducive to pro- moting quality patient outcomes and employee well- being.” Attributes of an authentic leader that are essential for establishing and maintaining a HWE include genuineness, trustworthiness, reliability, ‘compassion, and believability." An effective leader seeks to (1) balance the tension between production and efficiency; (2) create and sustain trust through- ‘out the organization; (3) actively manage the process of change; (4) involve workers in decision making pertaining to work design and work flow; and (5) use knowledge management to establish the organi- zation as a learning organization. The Synergy Model ‘The synergy model, developed by the AACN, has served as the foundation for certified practice since the late 1990s." It is the conceptual model for under- graduate and graduate curricula and has been used ina variety of clinical settings as the basis for job descriptions, performance appraisals, and career advancement.!* The underlying premises of the synergy model are (1) patients’ characteristics are of concern toPART INE The Concept of Holism Applied to Critical Care Nursing Practice SHARACTE} onsee RSTieg uinerabity aking (Characteristics of Patents, Clinical Units, and Systems of Concern to Nurses arcipaton in decision making extn o which pationamily engages decision making + Siabiy—the abit fo maintain steady-state equloium + Resileney—the capacty to relum to a restorative lve of uncioning using compensatoryleping mechanisms; the bit Bounce back quied after an insult + Complesty—ineinticateentanglemant of twa or mare systems (2.9. body family, therapies) + Pateipaton in care—extert to which patertfamy engages in aspects of care + Rasoutesavalabity— extent of resoureas (eg, tacrieal, Neal personal peychologlal, and soc) ho atentTamiycommunty beng the ston + Prditabilty—tne abst to expect a caain course of events or cours of ness + Vulnerability suscepti to actual or polantal stressors tat may advert affect patont outcomes ‘Nurse Competencies of Concern to Patients, Clnial Units, and Systems *Cinealjudament~cines reasoning which inchs cniea! doesion making, rial thinkin, and lobal graepof| ‘ha stuaton, coupled wih nursing sls acquired tnough a proces af rtgratng formal an informal exper nowiedge and evidenes based guidelines + Advocacy and moral agoney—workng on anther’ bshalf and presenting the concoms ofthe pationtfamly and ‘uteng sa easing as a moral agent inidebiyng and helpngf eacve efi! ang neal cenoems win snd Satie the trea sting, + Caring practices —rursing actviiss that crate a compassionata, supportive, and therapeutic environment fr ptionts ‘a staf, wits tbe am of promoting comfort and healing and preventing unnecessary suring includes, cut not Entod'o, wguance, engagement, nd esponsivenoss of caregivers eluding arly and hoatheare personel + Colaboraton—working with otors (9. pains, familie, healthcare provers) na way that promesTencourapes ‘ch person's contrbutons toward achlewng optinaiteactepainfamly goa: voles ntadsupnary and Intorscipsnary wrk wih clloagues and communty + Systoms thinking —Do0y of knonledge and tol nat allow te nee to manage whatever environmental and sytem resources ex forthe patlerfemly and staf. witun or across healthcare and non-helcare systems + Responsofo ivrsity—e sonst to recognize, appreciate, and incorporate aiferences int he provision of car; ferences may include, but ae net miedo, cura ferences, spitul betes, gender, race, oly, ese, Sosoeconemie satu, age, and val + Cina ingiry Grnovatrevalalor the ongoing proces of questioning and evaluating races and proving 'sformed practes ereaing pracce changes though research ulizaton end experiential earnng + Factato of earring—the ably f facia earsng for patents, pursing staf, ter members ofthe heathare tam, and community nludes both formal and informal faction of leaning riguae Unit, or system (élue) nurses; (2) nurses’ competencies are important to patients; (3) patients’ characteristics drive nurses’ competencies; and (4) when patients’ characteristics and nurses’ competencies match and synergize, out- ‘comes for the patient are optimal." Bight character- istics (of patients, units, or systems) and eight nurse competencies that constitute nursing practice form |. The syneroy model. Synergy results when the needs and characteristics of a patent, clinical matched witha nurse's competencies (green) the basis of the model (Fig. 1-1). Patientiunit/system characteristics range depending on the situation and are expressed as level 1, 3, or 5, with 1 being “low” and 5 being “high.” Similarly, nurse competencies range depending on the nurse's level of expertise, and are expressed as level 1, 3, or 5, with 1 being “competent” and 5 being “expert.”The synergy model is used to evaluate the rela- tionship between clinical practice and outcomes Patient-derived outcomes may include functional change, behavioral change, trust, satisfaction, com- fort, and quality of life. Nurse-derived outcomes may include physiological changes, absence of com- plications, and the extent to which care or treatment objectives are attained. Healthcare system-derived ‘outcomes may include reduced recidivism, reduced costs, and enhanced resource utilization. STUDY Mss. c., an 82-year-old woman, is brought by ambulance to the emergency room because she is experiencing left-sided weakness and difficulty with speech. Mrs. C., an insulin-dependent diabetic who had an acute myocardial infarction 2 years ago, lives at home alone but is checked on frequently by family members. Mrs. C. has limited financial sup- port. Today, her granddaughter stopped by to check on her and called 811 when she noticed that Mrs. C. was having trouble speaking, Inthe emergency room, the healthcare team assessed Mrs, Cs neurological status using the National Institutes of Health (NIH) stroke scale, CT studies were negative for hemorrhagic stroke. She was admitted to the critical care unit for ischemic stroke. The critical care nurse performed a bedside swallow evaluation prior to administering oral medi- cation. Based on this evaluation, the nurse decided to obtain a speech therapy consul to perform a more comprehensive swallow examination. The ‘oral medication was held until the evaluation could be performed. Mrs. C’s son arrived at the hospital to visit his mother; although he came during non- Visiting hours, the nurse allowed him to visit with his mother, and provided him with a pamphlet that provided information regarding the critical care unit environment, what to expect, and visitation hours. Because Mrs. C. is currently unable to make her own healthcare decisions, her son provided the hospital with a copy of his mother’s power of attor- ney for healthcare, which identified him as the pri- mary decision maker. 41. Which patient characteristics are concerns for Mrs. C.? 2. By performing the swallow evaluation and obtain- ing a speech therapy consult, the critical care nurse demonstrated which nurse competencies? 3.Allowing Mrs. C's son to visit even though his, Visit did not coincide with standard visiting hours demonstrates which nurse competencies? Critical Care Nursing Practice SHAPTEH 1 7 References 1. Kaplow R: The value of certification. AACN Adv Crit Care 2(1)25-32, 2011 2, Melnyk BM, Fineout-Overholt B: Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. Philadelphia, PA: Lippincott Williams & Wilkins, 2010 3. Stafileno B, McKinney C: Evidence based mursing. Nurs Manag $2(6):10-14, 2011 4, Schulman €: Strategies for starting a successful evidence based nursing program, AACN Adv Crt Care 19(3):301-31 2008 ‘oint Commission on Accreditation of Healtheare ‘Organizations. Retrieved June 15, 2006, from htpswww. jointcommission. orgyNR 6, Maxfield D, Grenny J, MeMillan R, et al: Silence kill: The seven crucial conversations for healthcare. Retrieved from htpsiwww.aaen.onyaacnpubpoley.nst 17, Gardner DB: Ten lessons in collaboration, Online J Issues Nurs 10(1):2, 2005 8, DiAmour D, Ferrada-Videla M, San Martin Rodrigue? L, ‘tal The conceptual basis for imterprofessional collabora- tion: Core concepts and theoretical frameworks. J Interprof Care 19(suppl1):116-131, 2005 9, Laalley D: Physician-Nurse collaboration and patient sales. Forum 26(2), 2008 10, Schmalenterg C, Kramer M: Clinical units withthe healthi- ‘est work environments, Crit Care Nurse 2865-67, 2008 1, Kramer Mf, Maguire P Brewer B: Clinical nurses in Magbet hospitals confitm productive healthy unit work ensiron- ‘ments. J Nurs Management 19(1):5-17, 2011 12, Briggs L, Schriner C: Recognition and support for today’s preceptor. } Contin Educ Nurs 41(7)317-822, 2010 13, Mastal M, Joshi M, Schulke K: Nursing leadership: Championing quality and patient safety in boardroom. Nurs ‘2007 1. ic leaders creating healthy work cavi- wg practice. Am J Crit Care 15(4):256- 15, American Association of Critical-Care Nurses Certification Corporation: The AACN Synergy Model for Patient Care Retrieved June 15, 2006, srom hutpew.certearp org! cert- ccorpicertcorp nsfivwdaciSynModel 16, Reed KD, Cline M, Kerfoot KM: Implementation of the synergy model in critical care. In Kaplow R, Hardin SR. (Cds): Critical Care Nursing: Synergy for Optimal Outcomes. ‘Sudbury, MA: Jones & Bartlett, 2007 ‘Wantto know more? Awidevaretyoresoutcestoenhanceyourlearn- ing and understanding ofthis chapter are available on wsPal-. Visit hitp:/Mhepoint.tww.com/MortonEsste to access chapter review ‘questions and more!