Professional Caring and Ethical Practice Study Guide for the CCRN

Systems Thinking and Patient Characteristics

Nurses often hear that critical thinking is the basis of best patient care. Systems thinking is also extremely important and works with the aspect of critical thinking. Nurses must bring in their previous knowledge and experiences to provide the best care.

AACN® Synergy Model

Systems Thinking Model

The AACN Synergy Model discusses the nursing competency of systems thinking. Systems thinking is the ability to manage resources to solve patients’ problems both in and out of the healthcare environment. Nurses must understand how healthcare system structures and community structures work and how their processes can affect patient outcomes.

As with other competencies in the AACN Synergy Model, systems thinking is defined on a level system.

• In Level 1, the nurse believes he/she is the only resource to help the patient and does not negotiate with the patient or others.

• In Level 3, the nurse develops the ability to look at and negotiate resources outside of a personal level.

• Finally, in Level 5, the nurse becomes an expert in the understanding of the healthcare system, availability of resources, and the negotiation processes that allow them to best care for the patient.

Systems Thinking

The interrelation of different systems promotes a way of thinking that maximizes patient and family care. Systems thinking is not a single concept, but a collection of concepts that work together. These concepts include individual responsibility, learning process, vision, team process, and system organizations.

The organization-wide perspective that nurses develop is essential to systems thinking. Nurses must take initiative to be consistent in their approach, implement effective change measures, and collaborate with their team members. Nurses must work together to define issues in healthcare, describe the behaviors that may be troublesome, establish cause-effect relationships, identify different patterns of behavior, find solutions, and institute improvement activities to make changes for the better.

Barriers

Several situations can become barriers to a systems thinking approach. Nurses may experience these throughout their career. Some barriers to systems thinking include forgetting the purpose of a patient’s care, feeling victimized, relying solely on past experience, self-centered views, inability to adapt to the situation, and weak group dynamic and decision making.

Patient Characteristics

As mentioned earlier in this guide, the AACN Synergy Model discusses both nursing and patient characteristics. Nurses must consider patient characteristics in order to match their learned competencies to the needs of the patient and the family. The AACN believes that nurses must be aware of their patients’ resilience, vulnerability, stability, and medical complexity. Knowing the base characteristics of patients and their families will help the nurse decide how to navigate their care plans.

Patient Care

Nursing care can be influenced by several external forces. Patients come from all different environments. They will have expectations of the care provided, as will the society from which they come. Nursing care can be influenced by social expectations to perform certain types of therapies and to provide equal care to all patients.

Nursing care can also be influenced by political forces, as both local and federal governments can have a say in the type or extent of care allowed per patient scenario. Building on the political force, regulatory forces (represented by local, state, or federal law) limit or permit specific medical care. Depending on each region’s legislation, medical care allowances can differ greatly between regions.

Finally, economic forces can impact the ability to care for patients. Management and cost-containment committees try to manage the costs of medical care to reduce unnecessary spending. This can limit the types of care provided at individual facilities due to reduction of care overlap. It can also regulate a facility’s access to specific supplies or equipment.

Quality Care

Nurses must provide quality patient care. In order to do this, nurses must stay up to date with the recommended best healthcare practices; be accessible to the patient regardless of personal situations; help coordinate care among all healthcare providers; strive to achieve desired outcomes; be efficient in care; prevent unnecessary problems; respect the medical team, patient, and their family; and practice safely.

Clinical Inquiry

The final nursing competency is clinical inquiry. Clinical inquiry is the desire and process of continual evaluation and development of evidence-based research to improve nursing outcomes. Nurses must use clinical inquiry throughout their career to ensure they are practicing the most up-to-date recommendations.

AACN Synergy Model

The AACN Synergy Model defines how clinical inquiry can be used in nursing. Nurses must utilize their resources to gain knowledge while seeking additional learning. They must be open to mentoring and teaching from other experienced medical professionals. They must be competent in identifying problems and implementing adequate problem-solving skills. Nurses must also be able to read and interpret research in order to apply the aspects of it to current practice. And finally, nurses must be willing to participate in medical research.

Three levels exist to determine how greatly a nurse can incorporate clinical inquiry into his/her workflow.

• In Level 1, nurses can only recognize that problems exist and seek others to provide advice or follow general facility guidelines.

• In Level 3, the nurse begins to question industry standards and clinical practice while beginning to seek knowledge and education to improve that practice.

• The highest level, Level 5, shows the nurse’s ability to pull away from industry standards with research and evidence-based practice. The nurse at this level develops ways to improve and teach improved patient care.

Evidence-Based Practice

Evidence-based practice is the implementation of evidence-based research outcomes. This can be reflected in all medical branches as new research constantly develops newer and better processes. There are several things that nurses must know about creating and/or implementing evidence-based practice guidelines.

First, nurses must understand what they are trying to accomplish with the evidence-based research and processes being questioned. Nurses should create an outline of a potential intervention to understand the step-by-step process of research to procedure implementation. This outline should include research recommendations, ideal patient population, specific medical equipment/procedure needs, and intended outcomes.

Second, nurses must complete a thorough evidence review and review of literature to ensure that what they want to implement has been thoroughly studied and tested among various populations. In addition to the literature collection, nurses may gather expert judgement regarding an intervention. Experts in the medical field often have some experience implementing or changing policies based on evidence-based research. While this knowledge is useful, do not rely on it alone to develop practice changes.

Third, nurses must look at the proposed changes through the eyes of the medical facility. Considerations for cost, time, patient access, qualified staff, and legal implications are essential to the success of the proposed changes. Many research ideas cannot be adequately implemented without the support of the overlying medical facility.

Fourth, nurses must create a policy with appropriate recommendations. Nurses must use high-quality research and evidence to promote their change. Research quality is often graded on a letter base scale with A as the highest grade of evidence.

Finally, nurses must review the policy they have developed. Peers and other medical professionals should be utilized to read and make recommendations to the policy prior to implementation of the changes.

Critical Reading

In addition to understanding the basic research concepts, nurses must understand how to critically read and evaluate research. Nurses must consider where the research articles come from as well as the author’s credentials to determine if the author was an expert in their subject. They must read actively to determine the article’s thesis, process, and outcomes. When doing this, the nurse should also analyze the organization of the article to ensure that the research follows a theory to the end and has methodological organization.

After going through the structure of the article, the nurse should compare the evidence to the main points of the article. The evidence should support the main points and not stray from the topic. The nurse should also assess the sample population to ensure that the research has applicability outside of a small, limited group. Finally, the nurse should review the overall article to determine its credibility and usefulness to the nurse’s objective. Only after critically reading and accepting an article should the nurse take the research back to his/her facility.

Research Structure

Research can become extremely complex. Nurses must understand how to break down research in order to be able to understand and implement the changes necessary in practicing evidence-based care.

Basic Research

Nurses must remember the basic research concepts in order to secure their footing in it. These concepts include using and surveying valid sources; thoroughly evaluating internal and external validity; and consciously choosing samples and sample size based on the needs of the research.

Hypothesis

Research articles are made of many components. These components all revolve around a central hypothesis. A hypothesis is an idea or statement that is developed to describe a predicted outcome based on a specific intervention (or lack thereof). The study then focuses on proving this statement through extensive data collection.

Data

Research cannot move forth without data. Review the common ways to get data, data types, and challenges with data collection.

Data Collection

Data analysis, laboratory findings, and external testing play key roles in testing a hypothesis. Once a hypothesis is developed, these pieces must be investigated to ensure that the hypothesis can be proved. Studies should define a control group and a testing group to help support test outcomes while supporting the validity of data collection. If the data does not support the hypothesis, then a new hypothesis must be created or different testing methods implemented to better address the original hypothesis.

Data Types

Two types of data exist: qualitative data and quantitative data. Qualitative data is subjective in nature. It can be collected via conversations, interviews, and visual images. It is generally very easy to collect but is time-sensitive and is difficult to generalize to larger population groups.

Quantitative data, on the other hand, is objective, statistical information and number data collection. Quantitative data can be collected through surveys, questionnaires, numerical grading scales, and other statistical data collection measures. It can be better generalized to larger populations and may be collected actively or retrospectively.

Data Bias

Throughout data collection, researchers must also be careful of bias. Research should be unbiased as much as possible to prevent artificial results. Selection bias can develop if a group of research subjects does not match the representative population. This is more likely to occur if subjects are specifically picked for a study, rather than generated from a list of potential subjects based on specific criteria.

Information bias can develop if there is a classification error. These errors will skew results. Information bias can involve non-differential misclassification or differential misclassification.

Validity, Generalizability, and Replication

After identifying or creating a hypothesis, nurses must be able to interpret a study’s validity, generalizability, and replication of results.

Two types of validity exist: internal validity and external validity. With internal validity, researchers want to ensure that data is unbiased, properly collected, and analyzed specifically for the population studied. External validity refers to the ability of the outcomes in the test population to be generalized to other populations.

Test results should also be able to be replicated in another, similar study and result in similar outcomes. Studies that are not able to be replicated are deemed to be inaccurate, too population-specific, or unreliable. Assessing a study’s replication ability can identify gaps in the research due to population exclusion or inclusion. These parts should all be evaluated thoroughly and changed as needed to produce the most valid, reliable research.

Outcome Evaluation

Research is not complete until the outcomes are evaluated against the hypothesis. Both internal and external research can be used to evaluate outcomes. Researchers will want to determine if their outcomes are positive and then help develop the appropriate policy and protocol changes.

Throughout the research process, researchers should closely monitor the study subjects throughout the course of treatment and record their reactions to any implemented interventions. When reviewing patient records, it is important to assess if outcomes fall within acceptable parameters. After therapy interventions are complete, the researchers should continue to monitor patients for a specific amount of time to determine the effectiveness of treatment. Finally, if treatment is found to be ineffective through an outcomes evaluation, the treatment must be changed.

Critical/Clinical Pathways

After research is completed and tested, it will become the responsibility of medical professionals to implement the evidence-based changes among their staff. Critical/clinical pathways can assist these professionals in outlining a streamlined way of disseminating information and making the recommended changes.

Several steps create the critical/clinical pathways. Researchers need to establish an involved interdisciplinary team that is on board with the research objectives and becomes part of the pathway development for data collection and therapy implementation. This team should have open communication and frequent discussions to identify any concerns and reach consensus on conflicts. This group will be instrumental in pilot testing the research and developing changes or redirections of the project as needed. Patients should be selected for the research based on predetermined parameters and patient or research needs.

A literature review should be completed to see where quality improvement opportunities lie. Researchers should also identify the areas of data collection, including categories of patient care. This data collection will become important in identifying pathways or variances from anticipated research outcomes. It can also be used to ultimately improve the overall study and implementation of future policies and procedures.