AACN Essentials Domain 1: Knowledge for Nursing Practice
“Focuses on the discipline of nursing knowledge and other disciplinary knowledge.” (AACN, 2021, p. 27).
AACN Essentials Domain 7: Systems-Based Practice
“Focuses on complex systems-based practice” (AACN, 2021, p. 44).
Domain 7: Essential Knowledge
To meet the objectives for Domain 7, knowledge is required in:
- Complex healthcare systems at the macro-, meso-, and micro- levels
- Systems across continuum of care
- Individual and global thinking
- System awareness, innovation, and design considering structural racism and systemic inequity
- Predicting change to develop future strategies
- Fiscal accountability
- Leadership in evidence-based solutions
Domain 7: Leveling of the AACN Essential Objectives
“7.1 Apply knowledge of systems to work effectively across continuum of care.” |
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| Beginning of Program | Middle of Program | End of Program | |
| “7.1e Participate in organizational strategic planning.” | Complete a gap analysis to identify internal system-processes that do not align with the mission and vision of their clinical site. | Analyze data on the impact of the project on organizational stakeholders. | Create a quality improvement plan to address the identified gaps. |
| “7.1f Participate in system-wide initiatives that improve care delivery and or outcomes.” | Participate in ongoing quality improvement initiatives at practice setting to promote quality outcomes. | Analyze data to identify priority opportunities for quality improvement at the practice setting. | Recommend a system-wide plan to improve care delivery and/or outcomes. |
| “7.1g Analyze system-wide processes to optimize outcomes.” | Outline opportunities for system-wide process improvement based on relevant evidence-based practice. | Recommend changes in current processes to address system-wide process related to clinical practice to support quality outcomes. | Formulate a plan to address priority process changes to facilitate measurable quality outcomes. |
| “7.1h Design policies to impact health equity and structural racism with systems, communities and populations.” | Identify both internal and external processes that impact health equity. | Explore external systems to address inequities that negatively impact health equity and structural racism with systems, communities, and populations. | Create policies that improve access and quality of care to address health equity, and structural racism with systems, communities, and populations. diverse populations. |
“7.2 Incorporate consideration of cost effectiveness of care.” |
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| Beginning of Program | Middle of Program | End of Program | |
| “7.2g Analyze relevant internal and external factors that drive healthcare costs and reimbursement.” | Discuss internal and external factors that impact healthcare costs and reimbursement. | Analyze the internal and external factors that impact healthcare costs and reimbursement to identify gaps and mitigation strategies. | Formulate a plan relevant to internal and external factors that address healthcare costs and reimbursement considering an organizations mission. |
| “7.2h Design practices that enhance value, access, quality, and cost effectiveness.” | Explore current institutional practices related to value, access, quality, and cost effectiveness. | Analyze evidence-based literature for evidence-based practices to identify opportunities to improve practice. | Develop a strategic plan that enhances the value, access, quality, and cost effectiveness of the services provided by the organization. |
| “7.2i Advocate for healthcare economic policies and regulations to enhance value, quality, and cost-effectiveness.” | Identify current healthcare economic policies and regulations being utilized by the organization. | Examine opportunities to advocate for change related to healthcare economic policies and regulations to improve value, quality and cost-effectiveness. | Develop a strategic plan for healthcare economic policies and regulations that enhance value, quality, and cost-effectiveness of the organization. |
| “7.2j Formulate, document, and disseminate the return on investment for improvement initiatives collaboratively with an interdisciplinary team.” | Demonstrate an ability to collaborate with members of the interdisciplinary team to identify quality improvement initiatives. | Analyze in collaboration with the interdisciplinary team priority initiatives to enhance value, access, quality, cost effectiveness, and current return on investment. | Create a report in partnership with an interdisciplinary team highlighting the return on investment for quality improvement initiatives. |
| “7.2k Recommend system-wide strategies that improve cost-effectiveness considering structure, leadership and workforce needs.” | Identify current and evidence-based system-wide strategies that improve cost-effectiveness, consider structure, leadership and workforce needs. | Compare the current with evidence-based system wide strategies that improve cost-effectiveness, consider structure, leadership and workforce needs. | Formulate a plan for implementing evidence-based system wide strategies that improve cost-effectiveness, consider structure, leadership and workforce needs focused on the individual priorities of an organization. |
| “7.2l Evaluate health policies based on an ethical framework considering cost-effectiveness, health equity, and care outcomes.” | Review health policies based on an ethical framework considering cost-effectiveness, health equity, and care outcomes. | Analyze the current health policies based on an ethical framework considering cost-effectiveness, health equity and care outcomes. | Recommend health policies based on an ethical framework considering cost-effectiveness, health equity, and care outcomes. |
“7.3 Optimize system effectiveness through application of innovation and evidence-based practice.” |
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| Beginning of Program | Middle of Program | End of Program | |
| “7.3e Apply innovative and evidence-based strategies focusing on system preparedness and capabilities.” |
Identify innovative and evidence-based strategies focusing on system preparedness and capabilities. | Develop an evidence-based protocol to address one specific area of identified opportunity of improvement related to system preparedness and capabilities. | Design an evidence-based protocol supporting system preparedness and capabilities. |
| “7.3f Design system improvement strategies based on performance data and metric.” |
Analyze data and metrics to identify a priority system improvement. | Critique literature to identify evidence-based strategies to address the priority system improvement. | Formulate a strategic plan to facilitate quality improvement outcomes. |
| “7.3g Manage change to sustain system effectiveness.” | Outline evidence-based strategies that facilitate sustained system effectiveness to sustain change. | Determine strategies to facilitate sustained system effectiveness for a priority change within an organization or practice site. | Develop an ongoing performance improvement plan to effectively manage change and sustain system effectiveness. |
| “7.3h Design system improvement strategies that address internal and external system processes and structures that perpetuate structural racism and other forms of discrimination in healthcare systems.” | Identify evidence-based practice strategies to reduce internal and structural racism and other forms of discrimination in healthcare systems. | Evaluate organization processes and structures that reduce or perpetuate structural racism and other forms of discrimination of healthcare systems. | Develop an action plan to reduce structural racism and other forms of discrimination in the healthcare system. |
Domain 7: Teaching/Learning Strategies
Examples of Clinical/Practicum Strategies
Example 1: Case Scenario
Description: This case scenario could be used as an individual assignment, team assignment, discussion board, or developed as a simulation.
Directions: For this example, the assignment was developed for students to work in pairs to develop a presentation, which will be recorded using (insert your programs platform for example Microsoft Teams, Zoom or another platform).
You are encouraged to use (identify program platform for example Microsoft Teams, Zoom or another platform) to meet as a group and share and collaborate on group work.
Presentations should not exceed 20 minutes.
Case Scenario
You are working as a PMHNP in a community psychiatric-mental health clinic and asked to complete an initial psychiatric-mental health intake assessment for the following individual who has traveled 90-minutes for her appointment with you today.
A 26-year-old single female presents feeling depressed and hopeless. Her sleep is disturbed, as she awakens intermittently throughout the night with vivid flashbacks and/or is awakened to care for her newborn. Additionally, she experiences intense cravings to drink alcohol, specifically vodka, which leads to a downward spiral of use of methamphetamines and suicidal ideation, along with feelings of guilt and shame. She successfully completed a 28-day substance use disorder program approximately one year ago prior to becoming pregnant and has sustained her recovery since completing the program. At the time of the appointment, she reports intermittent suicidal ideation but is superficial and vague when asked about a plan.
She recently lost her job after returning from FMLA after the birth of her daughter. The reason for the job termination was explained by her supervisor as an inability to perform job functions, including a loss of focus and attention to detail which she explained as an inability to concentrate and make decisions in her daily work. The individual reports racing thoughts, feeling depressed, empty, hopeless, lack of interest or pleasure in daily activities, loss of appetite, low energy, and extreme fatigue. The individual expresses feelings of guilt for past decisions and is unsure she will be able to be a good mother to her newborn daughter. She states, “I am doing my best to buy her nice clothes and educational toys, but my credit balance is reaching its maximum.” She reports sleep as intermittent approximately three hours per night.
Additionally, the individual reports the recent death of her aunt related to complications of COVID. She was very close to her aunt and often stayed with her growing up after her mom remarried when she was 10 years old. She said she experienced emotional abuse from her stepfather and never felt like she really belonged or felt accepted by her stepfather. The individual’s biological father abandoned the family after coming to the United States. The individual reports her biological father drank heavily and had many physical and medical problems. She reports a positive and supportive relationship with her sister who lives in another state. She also reports being physically assaulted and emotionally abused by her past boyfriend, her daughter’s father, and has filed a protection order against him. The individual’s biological parents came to the rural community after being refugees. At the time the individual made the appointment, she was employed with private insurance, but she will no longer have private insurance at the beginning of next month, one week from today.
She reports being hospitalized when she was age 21 with suicidal ideation and depression and was diagnosed with Bipolar II Disorder and Borderline Personality Disorder. She stopped all her medications when she found out she was pregnant to protect her baby, and explained she didn’t want to be dependent on substances to manage her mental health. However, at the time of presenting to the community mental health clinic, her symptoms are intense, and she is now open to exploring medications due to the level of psychiatric-mental distress.
Instructions for Presentation
The presentation should:
- Identify priority individual presenting symptoms and assessments which contribute to the complexity of the individual’s care.
- Outline the assessment you should use, including specific assessment questions and screening/assessment tools you should integrate in the initial psychiatric-mental health assessment.
- Identify a DSM-5-TR Diagnosis and top three differential diagnoses.
- List the individual treatment goals written in SMART format to support quality outcomes.
- Explore data trends related to the priority psychiatric-mental health concerns with which this individual is presenting within your community/state/nation. Examples of topics you might consider include but are not limited to, substance use disorder, perinatal health, psychiatric-mental health, trauma, and prevalence of suicidal ideation.
- Compare public with private funding in the state(s) where you currently reside with an explanation of which advantages and disadvantages exist with each of these funding options. Outline your plan to maximize resources while ensuring cost effectiveness.
- Include a comprehensive management plan which includes pharmacological and non-pharmacological/therapeutic management strategies.
- Include specific examples of how and when you should integrate the following psychotherapy modalities within your assessment and the management plan.
- humanistic
- cognitive-behavioral therapy
- dialectical behavioral therapy
- motivational interviewing
- mindfulness
- Include psychoeducation.
- Include community referrals.
- Integrate interprofessional collaboration.
- Address ethnic and cultural considerations.
- Address social determinants of health.
- Address ethical concerns.
- Address organizational policy at the community mental health center you believe would be essential to support quality individual care for this individual.
Domain 7: Resources
Articles/Textbooks
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed). American Psychiatric Association.
Boland, R., Verduin, M., & Ruiz, P. (2021). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (12th ed.). Wolters Kluwer.
Conti, I., & Gilkinson, C. (2021). Preparing students for psychiatry OSCE’s in the COVID-19 pandemic. How can PsychSocs help? BJPsych Open, 6(7), (S1), S16–S17. https://doi.org/10.1192/bjo.2021.101
Gawlik, K. S., Melnyk, B. M., & Teal, A. M. (2021). Evidence-based physical examination: Best practices for health and wellbeing assessment. Springer Publishing.
Joung, J. & Kang, K. I. (2022). Can virtual simulation replace clinical practical training for psychiatric nursing? Issues in Mental Health Nursing, 43(8), 706-11. DOI: 10.1080/01612840.2022.2055684
Pantziaras, I., Fors, U., & Ekblad, S. (2015). Innovative training with virtual individuals in transcultural psychiatry: The impact on resident psychiatrists’ confidence. PloS One, 10(3), e0119754–e0119754. https://doi.org/10.1371/journal.pone.0119754.
Wheeler, K. (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. Springer Publishing.
Godfrey, M. M., Foster, T. C., Johnson, J. K., Nelson, E. C., & Batalden, P. B. (2024). Quality by design: A clinical microsystems approach (2nd ed.). Josey-Bass.
Oehlert, J. K., & Sitzman, K. (2024). A Holistic approach to disrupting with love and human caring. Cognella.
Websites
Patient Safety Network (PSNET)
Buprenorphine Quick Start Guide (see scenario)
Buprenorphine: Quick-start Pocket Guide (see scenario)
The Microsystem Academy
Systems Thinking (You Tube)
