NR 500 Discussion Systems-Structure and Function

The majority of nurses and advanced practice nurses today are working in complex adaptive systems. As science and evidence-based practice have evolved, so have complex adaptive systems (CAS). Complex adaptive systems or complexity science in nursing is a non-linear, unpredictable model of behavior with many diverse components that are interconnected, all functioning together towards new and improved care models (D’Agata & McGrath, 2016). CAS’s are interactive systems, involving an array of disciplines. They have multiple components that often challenge the way things were always done towards a new and improved method of thinking and doing that is science based. Once CAS’s are embraced by the healthcare community, great stride towards a better functioning healthcare system can and will evolve.

As a future nurse educator, I see the need for greater understanding and involvement in complex adaptive systems. One issue that I would like to see further advanced is that of family centered care in the neonatal intensive care unit (NICU) environment. Clinical nurse educators have become increasingly valuable resources to nurses, other healthcare disciplines, patients, and their families. This advanced practice role can provide the necessary education and role modeling that can ultimately transition current models of care into improved future models of care. As I researched this discussion question, I found a clinical issue that I could identify with and one that I would like to see my future role as a nurse educator impact. Through exploration of interconnected relationships between the parent, nurse, and patient, the need for increased parental involvement in direct care is an identifiable need for promoting the neurodevelopment in the NICU patient (D’Agata & McGrath, 2016). Educating nurses to allow for supportive parental caregiving right from the start in NICU stays, offers a stronger potential for improved parent attachment to their infant and possibly impacting premature brain development (D’Agata & McGrath, 2016).

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Premature infants are presenting to hospitals across our country with earlier gestations and more complicated medical needs than ever before. Their survival rates have greatly improved. However, the neurodevelopmental outcomes long after NICU stay is the clinical issue that needs to be addressed. There is rising evidence that poorer brain development caused by premature births lead to “cognitive, emotional, and behavioral deficits” (D’Agata & McGrath, 2016). Anxiety, attention deficits, autism, depression, cognitive deficits, and social difficulties have manifested in these individuals, long after NICU stay (D’Agata & McGrath, 2016). Family centered care is not a new concept in nursing, especially in the neonatal and pediatric settings. Incorporating the family into care, specifically the patient’s parents is one that is overall an accepted part of care but there is room for growth. In the NICU setting where the patient is in a complex and fragile medical state, the bedside nurse is the primary caregiver and coordinator of care for the baby. In an essence, the nurse acts as the gateway between newborn and parents.

Parents can often feel a lack of control or inadequacy in this type of situation. The neonate will likely experience factors that are abnormal early life experiences like stress, pain, and separation which can negatively affect the premature brain (D’Agata & McGrath, 2016). D’Agata & McGrath (2016) go on to describe research proving that chronic stress can alter the course for normal brain development. For example, a normal diaper change should not be a stressful event but accompanied by vital signs, heel sticks, repositioning, and bathing might be too much for a little one who has no reserve. Increased incorporation of parental participation in hands on care early in NICU stay has shown potential for improving short and long-term outcomes for the neonate (D’Agata & McGrath, 2016). The pathway of letting go of some of the rigidity that occurs in NICU care and adapting to a less linear approach to family centered care would help foster the crucial emotional connection needed to be formed between parent and child. The nurse educator can intervene by sharing recommendations for parental involvement with the staff and encouraging the incorporation of parents as co-care providers (D’Agata & McGrath, 2016). A nurse educator would educate NICU nurses on how to refocus their nursing care delivery by supporting them and helping staff to understand the need to coach and educate new parents in the NICU and ultimately piece the family unit back together.

At the microsystem level, there are infant-nurse-parent interactions. The direct care provided to the infant and the incorporation of family centered care is evidenced at this stage of complex adaptive care. The NICU department and the polices that the nursing staff are expected to follow in regards to family visitation and involvement in care is also part of the microsystem. The hospital that houses the NICU would be the mesosystem. The administrators and managers that direct the philosophy of this system ultimately affect nursing education and nursing care in the NICU (microsystem). The community surrounding the hospital is the macrosystem. Government legislation, funding, and research ultimately play a role at the macro level for complex adaptive systems as described. Improved access to technology and funding for advancement of research on neurodevelopment of the neonate at the macro level would trickle down to the mesosystem where a hospital administrator would see the need for nurse educator positions in the NICU, allowing for more open jobs. A nurse educator with a graduate degree would accept the clinical educator position in the NICU (microsystem) and implement the complex adaptive changes for improving parental involvement in the care of their infant through education, role modeling, and supportive care to the entire team. The embracement of a complex adaptive care system by the nursing profession, healthcare systems, various disciplines, and the community supports evidence-based practice and improved care for the NICU patient and family unit.

Reference

D’Agata, A., & McGrath, J. (2016). A framework of complex adaptive systems: Parents as partners in the neonatal intensive care unit. Advances in Nursing Science, 39(3), 244-256. doi: 10.1097/ANS.0000000000000127

Transitioning NICU care from where parents are ‘allowed’ to participate in simple care tasks to embracing them as partners in the primary care of their baby will empower the family unit. Improved support for each individual family, sharing and collaborating on care decisions will be evidenced at the microsystem level. While it may be a newer concept at first, I believe over time it would result in accepted practice at the micro level, much like kangaroo care became an accepted and now encouraged practice over time. D’Agata & McGrath (2016) described a study where this complex adaptive approach was implemented in a NICU setting. After 21 days of this type of intervention, a decrease in retinopathy was recorded as was an increase in breast feeding at discharge (D’Agata & McGrath, 2016). Decreased parental stress levels at discharge would also be a likely outcome at the micro level. At the mesosystem level, hospital leadership will likely see better patient outcomes and improved hospital ratings through standard survey methods that are sent out. This would open the door towards more administrative support of evidence-based practice at the micro level. At the macrosystem level, there has already been a trial called COPE (Creating Opportunities for Parent Empowerment) that supports “educational-behavioral intervention” focused on improving the mental and behavioral development of the child and supporting parent interactions (D’Agata & McGrath, 2016). Further funding and promotion of such programs will increase community awareness and healthcare systems will take notice and become more open to change.

Reference

D’Agata, A., & McGrath, J. (2016). A framework of complex adaptive systems: Parents at partners in the neonatal intensive care unit. Advances in Nursing Science, 39(3), 244-256. doi: 10.1097/ANS.0000000000000127

It is great to see members of upper level management taking an active part in delivering care to patients. When leaders such as DON’s and Unit mangers participate in caring for patients it makes fellow nurses want to become better leaders and caregivers within their profession. Teamwork, is one of the greatest benefits to nursing because it allows individuals to feel confident, prideful, and empowered. When upper level management takes an interest in the delivery of patient care nurses within the organization feel a sense of commitment to excellence and dedication to the organization for which they serve. Team work is considered to be a dynamic process encompassing an interplay of several factors (Polis, Higgs, Manning, Netto, & Fernandez, 2015). The benefits of effective teamwork for both patients and nurses are well documented and have proven to improve patient safety, reduce errors, and reduce mortality. At a system level micro, meso, and macro nursing education and team work interact hand and hand to deliver quality care.

Reference:

Polis, S., Higgs, M., Manning, V., Netto, G., & Fernandez, R. (2015). Factors contributing to nursing team work in an acute care tertiary hospital. Collegian,doi 10.1016/j.colegn.2015.09.002.

NICU family care centers is a great concept for nurses and families to assist with the bonding and healing between the infant and parent. Parents with infants in NICU at times feel guilty, anxious, fearful, and lost. Many times parents are not sure how they can help assist with the recovery of their infant and shy away from bonding and offering assistance. The monitor, cords, IV’s, and pumps connected to a tiny infant; to parents seem intimating and overwhelming. NICU care centers allow for the bonding and promote education needed to assist parents feel empowered and confident to help with simple task such as changing diapers, clothing, and cuddling with the infant. The American Family Children’s Hospital is one of many pediatric medical facilities that promotes a family friendly, nonthreatening place specifically designed to be patient and family centered in the care of sick infants and children (Pediatric Care Center, 2018). This concept of caring have proven to help improve the patient’s well-being and clinical outcomes (Pediatric Care Center, 2018). The NICU patient care concept can be properly designed at all systems level. The micro level is where the nurse educate and promote bonding between the infant and parent, in the meso level the directors and managers implement policies and procedures to promote a patient center unit, and at a macro level wide spread system change of care is promoted.

Reference:

PEDIATRIC CARE CENTER. (2014). Healthcare Design, 14(7), 180-183.

My specialty track is Family Nurse Practitioner (FNP). The issue that I have identified that is related to my specialty track is the increasing rise of opioid-related deaths and opioid addiction related to the over prescribing of opioids. Opioids are prescribed more frequently for pain that non-opioids or other non-pharmacological methods. Opioid over prescribing affects every level of system and by finding solutions for one level the others will be affected. As stated by Marquis and Huston (2012) a change in any element of the healthcare system causes changes in other elements of the system.

The overuse of opioid treatment for pain affects the system at the micro level by introducing opioids to opioid naive patients. By doing so this increases the risk of addiction to opioids. It also increases the probability of requesting opioids in the future for pain management. Opioid addiction can cause financial problems by the costliness of the prescriptions and resulting to buying opioids on the street if unable to get a prescription. Opioid addiction also causes family conflict and strains. At this level I would address the issue by decreasing the amount of opioid prescriptions for pain and use alternatives such as non-opioid treatment or non-pharmacological methods such as physical therapy, massage etc. Thompson (2017) stated that non-pharmacologic methods help to lessen patients’ focus on the time remaining until their next dose of opioids. By implementing this solution the amount of opioid prescriptions will decrease thus decreasing request for opioid prescriptions and opioids as first line of treatment for pain.

The overuse of opioid treatment for pain affects the meso level by increasing visits to the emergency department for chronic pain management. It also impacts the hospital by increasing opioid overdose and death related visits/admissions to the hospital. Psychiatric related visits are also increased due to opioid related addiction. Incidents involving violence in the hospital are also increased by opioid addiction. I will address these issues by not treating chronic pain in the emergency department. By not treating chronic pain in the emergency room setting there will be less visits for patients drug seeking thus decreasing incidents involving violence.

The overuse of opioid treatment for pain affects the macro level by increasing the cost to community through increasing cost of health insurance and home insurance. Increasing addiction rate correlates with increasing theft thus increasing home insurance. Emergency department wait times are increased with opioid addiction and drug seekers. HCAHPS scores asks about pain management and if the patient feels pain wasn’t properly managed than some organizations get decreased reimbursements. Legislation has started to decrease over prescribing of opioids. To address this issue I will advocate for increased legislation on opioid over prescribing. I will also increase education to the population of the dangers of opioids and alternative treatments to pain.

Marquis, B.L., & Huston, C.J. (2012). Leadership roles and management functions in Nursing: Theory and application (7th ed.). Philadelphia, PA: Lippincott, Williams, & Wilkins.

Thompson, C. A. (2017). HCAHPS survey to measure pain communication, not management. American Journal Of Health-System Pharmacy: AJHP: Official Journal Of The American Society Of Health-System Pharmacists, 74(23), 1924-1926. doi:10.2146/news170084

NR 500 Discussion Systems-Structure and Function