Session Number 108 CCRN-PCCN-CMC REVIEW: PROFESSIONAL CARING AND ETHICAL PRACTICES (SYNERGY) AND TEST TAKING STRATEGIES

Barbara Pope, RN, MSN, PCCN, CCRN popeb@einstein.edu Critical Care Clinical Educator Albert Einstein Healthcare Network Philadelphia, PA Content Description Synergy has represented 20% of the CCRN exam since July, 1999. The PCCN exam was developed based on the synergy model; synergy represents 20% of all PCCN questions as well. The CMC exam was developed with all questions based in synergy. This session will explore the development of AACNs Synergy Model and how it relates to the CCRN, PCCN, and CMC exams. It will look at the components of Synergy and present questions that are based on the Synergy model. In the second part of this presentation, test-taking strategies for the CCRN, PCCN and CMC examinations will be discussed. It will review the breakdown of each exam by percentage, and explore various study methods and the benefits of each. It will present construction of test questions and distracters. Learning Objectives At the end of this session, the participant will be able to: 1. 2. 3. List the nurse competencies that are described in the Synergy model Recognize a sample question as representing an area of Synergy Analyze the construction of a given test question to identify its intent

REFERENCES NOTE: Please refer to outline for references pertaining to this session.

CERTIFICATION REVIEW: Professional Caring and Ethical Practices (Synergy) and Test Taking Strategies Exam Tip: Approximately 20% of both the CCRN and PCCN exams will focus on Professional Caring and Ethical Practices, approximately 30 and 25 questions respectively. I. Professional Caring and Ethical Practices (Synergy) A. What is Synergy? AACN: Synergy is an evolving phenomenon that occurs when individuals work together in mutually enhancing ways toward a common goal. The Synergy Model creates a comprehensive look at the patient, putting the patient in the center of nursing practice. It identifies nursings unique contributions to patient care and allows us to define ourselves within the context of the patient and patient outcomes. B. Why Synergy? Prior to 1999, the CCRN certification exam was systems-based. All the certification exams are continually redesigned to maintain relevancy Changes in technology, nursing and consumers required a significant change in the exam. Did not look at individual patient needs Did not consider the family Did not look at the nurse Needed to look at practice based on patient and family needs Needed to look at nurse competencies that matched the needs of the patient C. More to Synergy than just certification Synergy a model developed by AACN Uses include: Patient Assignment Acuity system Development of Competencies Performance Appraisals Patient Outcome Assessment Career Advancement Utilization by Clinical Nurse Specialists D. Patient Characteristics The Synergy Model encourages nurses to view patients in a holistic manner rather than the body systems medical model. Each patient and family is unique, with a varying capacity for health and vulnerability to illness. Each patient, regardless of the clinical setting, brings a set of unique characteristics to the care situation. Depending on where they are on the healthcare continuum, patients may display varying levels of the following characteristics: Stability Complexity Vulnerability Ability to maintain a steady-state equilibrium Intricate entanglement of two or more systems Susceptibility to stressors that may affect patient outcomes

Resiliency Predictability Resource availability Participation in care Participation in decision-making

Capacity to return to optimal function using compensatory mechanisms Able to expect a certain course of events or course of illness Extent of resources the patient/family/community bring to the situation Extent to which patient and family engages in care Extent to which patient and family engages in decisionmaking

E. Nurse Characteristics Nursing care reflects an integration of knowledge, skills, abilities and experience necessary to meet the needs of patients and families. Thus, nurse characteristics are derived from patient needs and include: Clinical judgment Clinical reasoning, which includes clinical decision making, critical thinking and a global grasp of the situation, coupled with nursing skills acquired through a process of integrating education, experiential knowledge and evidence-based guidelines. Working on anothers behalf and representing the concerns of the patient/family and nursing staff; serving as a moral agent in identifying and helping to resolve ethical and clinical concerns within and outside the clinical setting. Nursing activities that create a compassionate, supportive and therapeutic environment for patients and staff, with the aim of promoting comfort and healing and preventing unnecessary suffering. These caring behaviors include but are not limited to vigilance, engagement and responsiveness of caregivers. Caregivers include family and healthcare personnel. Working with others (e.g., patients, families, healthcare providers) in a way that promotes/ encourages each persons contributions toward achieving optimal/realistic patient/family goals. Collaboration involves intra- and interdisciplinary work with colleagues and community. Body of knowledge and tools that allow the nurse to manage whatever environmental and system resources that exist for the patient/family and staff, within or across healthcare systems and non-healthcare systems. The sensitivity to recognize, appreciate and incorporate differences into the provision of care. Differences may include, but are not limited to, individuality, cultural, spiritual, gender, race, ethnicity, lifestyle, socioeconomic, age and values.

Advocacy/moral agency

Caring practices

Collaboration

Systems thinking

Response to diversity

Clinical inquiry

Facilitator of learning

The ongoing process of questioning and evaluating practice and providing informed practice. Creating changes through evidence-based practice, research utilization and experiential knowledge. The ability to facilitate learning for patients/ families, nursing staff, other members of the healthcare team and community. Includes both formal and informal facilitation of learning.

Although all 8 competencies are essential for contemporary nursing practice, each assumes more or less importance depending on a patients characteristics. F. Synergy Need to look at patient characteristics and nurse competencies Importance of nurse competencies will vary depending on the patients characteristics Synergy results when a patients needs and characteristics are matched with the nurses competencies How Synergy is used in the exam Will not be questioned on Synergy terminology Synergy theory applied to scenarios Reflects what nurses do Usually answer is common sense Example: Professional Caring and Ethical Practice The greatest family need during a patients first few days in the unit is to A. Participate in activities of daily living B. Plan discharge needs C. Feel that the best possible care is being provided D. Obtain information focusing on pathophysiology G. Clinical Judgment: 80% of the both CCRN and PCCN exam Systems-based Example: Clinical Judgment A 20 YO male patient is admitted S/P MVA. He was thrown from his all terrain vehicle and sustained a contusion of his right temple. He was reported to have had LOC for 10-15 minutes. The nurse would institute measures to prevent which potential problem in this patient? A. Epidural hematoma B. Concussion and frontal bone fracture C. Rhinorrhea and potential encephalitis D. Bilateral cerebral contusions H. Professional Caring and Ethical Practice (synergy): 20% of both exams Example: Advocacy/Moral Agency The nursing staff is resisting being assigned to a disruptive patient. An appropriate resolution would be to: A. Request the physician to transfer the patient B. Rotate the patient assignment among staff C. Confront the family and demand an end to the disruptive behavior

D. Hold a nursing team conference to discuss possible alternatives Example: Caring Practices A patient recalls a near-death experience (NDE) that occurred during resuscitation and wishes to tell the nurse about it. What is the optimal response by the nurse? A. Let the patient know that NDEs are often hallucinations B. Compare the patients story to the actual resuscitation events C. Encourage the patient to describe the NDE to his family D. Make time to listen actively while the patient tells the story Example: Collaboration A patient with Type I insulin-dependent diabetes mellitus is admitted in diabetic ketoacidosis (DKA). Since admission to the ICU, the patients glucose levels have been in the range of 400-500 mg/dl, and regular insulin has been administered on a sliding dosage scale. Given these findings, the most appropriate initial nursing intervention is to: A. Consult with the physician about changing the regimen to regular insulin via continuous drip B. Arrange for nutritional consult to enhance adherence to ADA diet C. Consult with the physician about increasing the maximum dosage of regular insulin on the sliding scale D. Request evaluation by the diabetic educator Example: Systems Thinking A major trauma victim is transported form a rural hospital. The patient died prior to the wifes arrival to the ICU. The nurse would best prepare for the wifes arrival by: A. Arranging for a physician to speak with her when she enters the unit B. Planning to escort her to the waiting room to await the physicians arrival C. Preparing to give her information about the care her husband received prior to death
D. Planning to escort her to the morgue to see her husband

Three examples of Response to Diversity 1. Diversity related to country of origin A 55-year-old man from Mexico is admitted to the PCU with hemodynamic instability related to urosepsis. Which of the following family members would be most appropriate for the nurse to include in teaching this patient about strategies to prevent future genitourinary tract problems? A. 54-year-old wife B. 59-year-old brother C. 78-year-old mother D. 82-year-old father 2. Diversity related to age Age-related changes found in older patients that may affect oxygenation and ventilation include which of the following: A. Increased chest wall compliance B. Decreased residual lung volumes C. Increased alveolar surface area D. Decreased FEV1 3. Diversity related to individual

A patient has just been admitted to the PCU from the Emergency Room with a diagnosis of gastrointestinal bleeding. She is alert and oriented, however very nauseated and adamantly about needing to call her son. The nurse says that she will call the son to notify him of his mothers admission. During the admission history, the nurse would like to assess the patients belief related to her admitting diagnosis. What question would provide the nurse with information for understanding the patients cultural beliefs related to hr diagnosis? A. When did you experience your first symptoms? B. Does anyone else in your family have this bleeding problem? C. Do you consume alcohol on a regular basis? D. Why do you think youre sick? Examples: Clinical Inquiry or Innovator/Evaluator 1. Which of the following leads is suggested to help distinguish ventricular tachycardia from supraventricular tachycardia with aberrant conduction? A. II B. AVL C. I D. V1 2. The preceptor for a new PCU nurse notices that the orientee is taking a noninvasive blood pressure measurement using the patients forearm rather than her upper arm. When questioned about this cuff placement, the orientee states that he had heard that the cuff could be placed on the forearm. The preceptor has never heard of using the forearm for this purpose and has no information on this change from standard practice BP technique. What should the preceptor do? A. Instruct the new nurse on the standard BP protocol of using the upper arm B. Take the blood pressure in both the upper and lower arms and then compare readings C. Design a research study to compare the relationship between upper and lower arm BP measurements D. Review the current literature to identify evidence and recommendations related to this change in practice Example: Facilitator of Learning or Patient/Family Educator A patient with heart failure is being transferred from ICU to telemetry after an acute episode of pulmonary edema. The nurse is talking to him about signs and symptoms that should be reported to his health care provider once he is back home. What should the nurse say to the patient to avoid a readmission? A. Report a weight gain of greater than 3 pounds over 3 days. B. Report fatigue and take an iron supplement to prevent anemia C. Be compliant with all scheduled appointments D. Limit your fluid intake to prevent shortness of breath II. Test-Taking Strategies A. Format of the exam Multiple choice questions CCRN: 150 PCCN: 125

CMC: 90 Completion time CCRN: 3 hours PCCN: 2 hours CMC: 2 hours Computerized Requires only two keystrokes Able to change answers First answer usually the best Also available by pencil and paper at Trends and NTI Pass/fail You will be told at the end of the exam that you passed or failed Paper and pencil will receive notification from AMP in six weeks Both include percentages for each section of exam B. Components of exam CCRN PCCN CMC A. Clinical judgment 80% 80% 100% Cardiovascular 20% 36% 74% Pulmonary 18% 14% 17% Multisystem 8% 5% Neurology 12% 5% 1% GI 6% 5% 4% Renal 6% 5% Endocrine 5% 4% 3% Hematology 2% 2% 1% Behavioral 4% 4% B. Prof caring and ethical practice 20% 20% Caring Practices 4% 4% Collaboration 4% 4% Facilitator of Learning 3% 3% Advocacy/Moral Agency 3% 3% Systems Thinking 2% 2% Response to Diversity 2% 2% Clinical Inquiry 2% 2% C. Whats the best way to prepare? Taking a class Studying from AACN self-assessment exams Studying from a book Studying from audio/video tapes Study groups D. Getting ready Preparation the night before Incorporated throughout all questions

Dont drink alcohol Dont stay up late studying Dont drink caffeine Lay out clothes
Preparation the day of Do not attempt a major review Dont drink caffeine Eat breakfast Wear comfortable clothing Layered clothing Arrive 30 - 45 minutes early E. Taking the exam Wear a watch Check that you have answered at least 50 questions in the first hour Dont spend more than 2 minutes on a question No penalty for guessing May be able to eliminate two choices Read question carefully Dont read into a question Dont think of atypical patients E. Analyzing questions Look for the answer that has a broader focus Look for qualifying words Be careful with negative words Avoid questions with absolute words Examples 1. Broad answer Two answers are correct; choose the one that provides the most information Billy Black is diagnosed with Wolff-Parkinson-White (WPW) syndrome. When evaluating his EKG, the nurse should note which of the following characteristics of this condition? A. PR interval < 0.12 second and wide QRS complex B. PR interval > 0.12 second and normal QRS complex C. Delta wave present in a positively deflected QRS complex in lead V1 and PR interval < 0.12 second D. Delta wave present in a positively deflected QRS complex in lead V6 and PR interval > 0.20 second 2. Qualifying words All answers may be correct; you need to determine which is most important. Qualify words: First, best, most, initial, better, highest priority Mr. Redman is admitted to the ED complaining of chest pain, despite receiving sublingual NTG. He is beginning to have PVCs and short runs of VT. What is the most appropriate nursing intervention? A. Administer another dose of NTG

B. Administer an IV bolus of Amiodarone and start an Amiodarone C. infusion C. Evaluate the patients mental and circulatory status D. Notify the ED doctor 3. Negative words Not used in the exam; poor test construction. Changes the nature of the question. Instead of looking for the correct answer, you are looking for the only incorrect answer. Examples of negative words: Not, least, except, inconsistent, all but, atypical, incorrect, false, unlikely, inappropriate, unrealistic, contraindicated. May also appear as physician orders that you would question. Mr. Redman is admitted to the ICU. He is still experiencing mild chest pain. Which of the following medications ordered by the physician would you question? A. Diltiazem (Cardizem) B. Propranolol (Inderal) C. Digoxin (Lanoxin) D. Meperidine (Demerol) 4. Absolute words Rarely is anything always the case. Avoid answers using these words: Always, every, only, all, never, none Which of the following is an accurate statement about cardiac chest pain? A. This pain always is caused by constriction or blockage of the coronary arteries by fatty plaques or blood clots B. True cardiac pain is never relieved without treatment C. This type of pain is relieved only by nitroglycerine D. Patients generally attribute the pain to indigestion 5. What to do when you havent a clue Avoid selecting an answer that you also dont understand! Remember that nursing care is similar in many situations Select the answer that seems most logical George Green, age 33, is diagnosed as having a pheochromacytoma. Appropriate initial nursing care would involve: A. Administering large doses of xylometazoline to help control the B. symptoms of the disease B. Closely monitoring Mr. Greens vital signs, particularly his blood D. pressure C. Preparing Mr. Green and his family for imminent death D. Having the family discuss the condition with the doctor before informing Mr. Green about the disease because of the protracted recovery period after treatment Another example. Look for the one thing thats not like the others.

For several years, Karen Cooper has been treated for severe chronic emphysema with bronchodilating agents and relatively high doses of prednisone (Deltasone). Which activity poses the least risk for triggering an adverse effect of prednisone therapy in this patient? A. Shopping at the mall on a Saturday afternoon B. Cleaning her two-story house C. Attending Sunday morning church services D. Serving refreshments at her 6 year-old sons school play F. Levels of testing Exam tests at different cognitive levels Level 1 - 36% of exam Knowledge and comprehension Level 2 - 39% of exam Analysis and application Level 3 - 25% of exam Synthesis and evaluation Example: Level 1 William Carlton is admitted to the PCU with acute exacerbation of COPD. Which of the following is the normal range for the PaO2 value? A. 10 to 30 mmHg B. 35 to 45 mmHg D. 10 to 20 cm H2O D. 80 to 100 mmHg Example: Level 2 William Carlton is becoming progressively short of breath. His ABG results are: pH 7.31; PaO2, 62 mmHg; PaCO2, 53 mmHg; HCO3-, 26 mEq/L Which problem do these values indicate? A. Uncompensated metabolic acidosis with moderate hypoxia B. Respiratory alkalosis with hypoxia C. Uncompensated respiratory acidosis with hypoxemia D. Compensated respiratory acidosis with normal oxygen Example: Level 3 William Carlton has become cyanotic and is experiencing Cheyne-Stokes respirations. What is the best action for the nurse to take at this time? A. Call a code blue and begin CPR B. Call Mr. Carltons doctor and report the condition C. Ensure that Mr. Carltons airway is open and begin supplemental oxygen D. Immediately administer the ordered dose of 200 mg aminophylline IVP G. Nursing process incorporated into questions Assessment - 32% Planning - 15% Implementation - 40%

Evaluation - 13% Example: assessment William Carltons respiratory status continues to worsen. Which of the following signs and symptoms would best indicate deterioration of his respiratory status? A. Increased restlessness and changes in level of consciousness B. Bradycardia and increased blood pressure C. Complaints of chest pain and shortness of breath D. Rapidly dropping PaCO2 and pH values Example: Planning William Carlton is diagnosed with acute respiratory failure and placed on mechanical ventilation with PEEP set at 10 cm H2O. Which of the following nursing diagnoses would have the highest priority for this patient? A. Impaired skin integrity related to immobility B. Decreased cardiac output related to changes in intrathoracic pressure C. Ineffective individual coping related to anxiety D. Impaired gas exchange related to decreased lung compliance Example: Intervention William Carlton has been on the ventilator for 3 days. He suddenly becomes extremely restless, and the pressure alarm sounds with each ventilator initiated inspiration. Which of the following would be an appropriate initial nursing action? A. Disconnect the ventilator and call a code B. Disconnect the ventilator and manually oxygenate the patient for a few minutes with a bag-valve-mask device C. Increase the ventilator pressure limit to 50 mmHg D. Remove the endotracheal tube and reintubate the patient with a tube one size larger Example: Evaluation William Carltons condition has improved and he is preparing for discharge. He needs to take oral theophylline at home for his lung disease. Which response indicates he has understood the nurses instructions? A. I can stop taking this medication when I feel better. B. If I have difficulty swallowing the time-release capsules, I can crush or chew them. C. If I become very sleepy when I take this medication, I need to cut back on the dosage. D. I need to avoid drinking coffee and caffeinated soft drinks while Im taking this medication.

Bibliography AACN Corporation (1999). Synergy Model: Adult sample Questions

Ahrens, T.S., Prentice, D., and Kleinpell, R.M. (2010). Critical Care Nursing Certification: Preparation, Review and Practice Exams, 6th edition. New York: McGraw-Hill Alspach, J.G. (Ed.). (2006) American Association of Critical Care Nurses Core Curriculum for Critical Care Nursing (6th ed.). Phila: W.B. Saunders Company. Alspach, J.G. (Ed.). (2008). AACN Certification and Core Review for High Acuity and Critical Care. St. Louis: Saunders Elsevier Chulay, M. and Burns, S. (2007) AACN Essentials of Progressive Care Nursing. New York: McGraw-Hill. Dennison, R.F. (2007). Pass CCRN! (3rd Ed) St. Louis: Mosby.-Elsevier Kaplan CCRN Certification for Adult, Pediatric, and Neonatal Critical Care Nurses, 2009 Edition (2009). Harwani, S.C., Contributing Editor. New York: Kaplan Publishing. Pope, B. (2009) Arm yourself with these test-taking strategies. Nursing 2009 Critical Care. 4(2). 40-43. Pope, B. (2002). Ready for synergy questions in the CCRN review? Nursing2002 32(5): (Critical Care). 32cc12-3. Pope, B. (2002) Rapid review: synergy. Nursing2002 32(6): (Critical Care). 32cc16. Sole, M.L.; Klein, D.G.; and Moseley, M.J. (2009). Introduction to Critical Care Nursing, 5th Edition. St. Louis: Elsevier Saunders Springhouse Review for Critical Care Nursing Certification, 4th Edition. (2007). Ambler, Pa: Lippincott, Williams, and Wilkins. Urden, L. D.; Stacy, K. M.; and Lough, M. E. (2010) Critical Care Nursing: Diagnosis and Management, 6th ed. St. Louis: Mosby Elsevier.