The Interdisciplinary Team Across the Continuum of Care

This case study demonstrates how the patient-focused implementation of teamwork by the critical care interdisciplinary team, under the leadership of the critical care clinical nurse specialist, contributed to the positive outcomes of a complex patient. The success of the interdisciplinary team’s work is reflected in the tenets of the Synergy Model: (1) the patient’s characteristics, (2) the nurses’ competencies, and (3) the resulting outcomes of the patient. The 8 patient characteristics include resiliency, vulnerability,stability, complexity, resource availability, participation in care, participation in decision making, and predictability. The 8 nursing competencies include clinical judgment, clinical inquiry, facilitation of learning, collaboration, systems thinking, advocacy and moral agency, caring practices, and response to diversity.

Our facility is a 400-bed, nonprofit community hospital in the suburbs of Chicago, Ill. The critical care unit has 23 beds, with an adjoining 4-bed open - heart recovery unit. The critical care interdisciplinary team includes the clinical nurse...