The Current Evidence Base for the Clinical Nurse Leader: a Narrative Review of the Literature

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Title The current evidence base for the clinical nurse leader: a narrative review of the literature.

Permalink https://escholarship.org/uc/item/4zk140n7

Journal Journal of professional nursing : official journal of the American Association of Colleges of Nursing, 30(2)

ISSN 8755-7223

Author Bender, Miriam

Publication Date 2014-03-01

DOI 10.1016/j.profnurs.2013.08.006

Peer reviewed

eScholarship.org Powered by the California Digital Library University of California THE CURRENT EVIDENCE BASE FOR THE CLINICAL NURSE LEADER:A NARRATIVE REVIEW OF THE LITERATURE ⁎ MIRIAM BENDER, PHD, RN, CNL

The clinical nurse leader (CNL) is a relatively new nursing role, introduced in 2003 through the American Association of Colleges of Nursing (AACN). A narrative review of the extant CNL literature was conducted with the aim of comprehensively summarizing the broad and methodologically diverse CNL evidence base. The review included 25 implementation reports, 1 CNL job analysis, 7 qualitative and/or survey studies, and 3 quantitative studies. All CNL implementation reports and studies described improved care quality outcomes after introduction of the role into a care delivery microsystem. Despite preliminary evidence supporting the CNL as an innovative new nursing role capable of consistently improving care quality wherever it is implemented, CNLs are still struggling to define the role to themselves and to the health care spectrum at large. Although the AACN CNL White Paper provides a concise model for CNL educational curriculum and end competencies, there is a compelling need for further research to substantively delineate the CNL role in practice, define care delivery structures and processes that influence CNL integration, and develop indicators capable of capturing CNL-specific contributions to improved care quality. (Index words: Clinical nurse leader; CNL; Review) J Prof Nurs 30:110–123, 2014. © 2014 Elsevier Inc. All rights reserved.

HE CLINICAL NURSE leader (CNL) is a relatively a comprehensive narrative review of reports describing T new nursing role, developed to enhance the CNL implementations and research on the role found efficiency with which care is delivered and to coordinate in the literature to date, as well as suggestions for and laterally integrate care through collaboration at the future study. microsystem with the entire health care team (American Association of Colleges of Nursing [AACN], 2007). Since Methodology its introduction in 2003, more than 200 reports have A narrative approach was used to summarize the current been published describing CNL theory, conceptual evidence regarding the CNL. Narrative review is consid- framework, education, and implementation. The role ered a valid strategy for organizing a comprehensive has been implemented in many health care organizations, knowledge base that is broad and methodologically with numerous reports of enhanced collaborative practice diverse (Collins & Fauser, 2005), such as the current and improved patient outcomes. This article presents CNL evidence base. A search of CINAHL, PsychINFO, Pubmed, and Dissertations & Theses was undertaken using the phrase clinical nurse leader, from January 1995 ∗ Lecturer, University of San Diego Hahn School of Nursing and Health to November 2011, with a repeat search in June 2012 to Science, San Diego, CA. Outcomes Research Specialist, Outcomes Research Institute, Sharp capture any newly released publications. The grey Healthcare, San Diego, CA. literature was also searched, including Google, Google Source of Funding and Conflict of Interest: The author has no conflicts Scholar, AACN Web site, AHRQ Innovations Exchange of interest to report and no competing financial interests exist. Web site, and a review of all references listed in extracted Address correspondence to Dr. Bender: Outcomes Research publications. The search returned 204 unique records. All Specialist, Outcomes Research Institute, Sharp Healthcare, 8695 Spectrum Center Blvd, San Diego, CA, 92123. E-mail: miriam.bender@ implementation and research reports on the CNL were sharp.com included in the narrative review. No reports were 8755-7223/13/$ - see front matter excluded on the basis of poor methodology, in the

110 Journal of Professional Nursing, Vol 30, No. 2 (March/April), 2014: pp 110–123 http://dx.doi.org/10.1016/j.profnurs.2013.08.006 © 2014 Elsevier Inc. All rights reserved. CURRENT EVIDENCE BASE FOR THE CLINICAL NURSE LEADER 111 interest of comprehensiveness. Explanatory, theoretical, and patient satisfaction; efficiencies in patient care or historical articles on the CNL; abstracts; journalism; processes and lengths of stay; improved nursing quality brief editorials; and articles addressing the CNL tangen- indicators such as falls, discharge teaching, sitter hours, tially were excluded from the review. The final sample and hospital acquired pressure ulcers; increased staff included 25 implementation reports, 1 CNL job analysis, registered nurse (RN) certification rates; improved home 7 qualitative or survey studies, and 3 quantitative studies health referral rates; decreased staff turnover; improved (see Figure 1). patient outcomes targeting infection rates, ventilator- associated pneumonia, transfusion rates, and restorative Results dining; and improved interdisciplinary communication and collaboration (see Table 1). CNL Pilot Implementations After the initial CNL White Paper was published in 2003, CNL Job Analysis The AACN established a CNL Implementation Task The Commission on Nursing Certification (CNC) Force (ITF) in 2004, charged with developing the authorized a job analysis in 2011 to establish the link curriculum and end-of-program competencies for CNL between CNL certification examination test scores and education, as well as a standardized evaluation frame- the competencies being tested (CNC, 2011). Job de- work for CNL pilot implementations (Bartels & Bednash, scriptions, journal articles, reference books, Web sites, 2005; Harris, Tornabeni, & Walters, 2006). Seventy-nine and other relevant search materials were reviewed to schools of nursing and 143 practice sites were involved in create a draft list of essential CNL skills and activities. An the first phase of the pilot CNL education and practice expert panel then worked to clarify performance implementations (Tornabeni, 2006). The ITF developed activities, knowledge skills, and abilities required of a numerous education/practice partnerships across the competent certified CNL. The results formed the basis of country to educate and train the first CNLs who a survey instrument sent (via e-mail) to 1,560 certified pioneered the role in their respective practice settings. CNLs across the country to validate skills and activities. The results of many of these pilot implementations, as The adjusted response rate was 16.7%. The survey well as independent CNL intervention trials, have been content was determined to be adequate: 98% respon- described in the literature. These reports describe the dents indicated that the survey either adequately or work completed through partnership between academia completely covered the important tasks performed by a and practice settings to operationalize the education and competent CNL. Reliability was calculated as Cronbach's clinical training of the first CNLs, and describe how alpha .99 for importance ratings. Although all respon- organizations operationalized the role within their dents were certified CNLs, only 26% were currently practice settings (for details please, see Table 1). The working in a formally titled CNL role. Other job titles articles report a host of quality improvements demon- included nurse educator (16%), staff RN (10%), and strated after CNL integration into various care delivery manager/director (13%). The rest were spread across a systems. These include the following: increased nursing wide swath of job titles. Fifty-nine percent worked in the time spent with the patient; improved staff, physician, acute care setting, 14% worked in schools of nursing,

Figure 1. Literature search flow diagram. 112 MIRIAM BENDER and the rest were evenly spread across a variety of difference evokes pride, (c) bringing the bedside point of outpatient environments. view, (d) knowing the patient as caring person, (e) living Tasks were bundled into 17 subdomains for CNL caring with nurses, and (f) needing to be known, practice. Respondents were asked to allocate percentages understood, and affirmed. CNLs saw the “big picture,” to the subdomains, reflecting the percentage of questions and therefore could connect the dots in terms of that should be assigned to each subdomain based on coordinating what patients needed from numerous perceived importance to practice. The results are shown disciplines and making sure “nothing fell through the in Table 2. The three most important subdomains for cracks.” This required prodigious amounts of tenacity CNL practice, as judged by certified CNLS, were (a) and perseverance, but was a great source of job evidence-based practice, (b) interdisciplinary communi- satisfaction and pride for each CNL. It was also the cation and collaborative skills, and (c) quality improve- source of the respect other practitioners developed for ment. The three least important perceived subdomains each CNL as their skills and commitment became for CNL practice were (17) health care policy, (16) health apparent. The CNLs had the time to get to know the care finance and economics, and (15) health care patient and families throughout their stay, which enabled informatics. them to translate what was happening throughout their admission in ways that were meaningful to the patients CNL Research and their families. This was doubly true for the nursing The CNL initiative is still in its infancy, and systematic staff: Because of the CNL's daily presence, they were able research on the CNL role is limited, but seven qualitative to forge relationships with the staff and mentor them and survey studies were identified that help to better through role modeling, actively assisting with complex understand the CNL in practice (see Table 3), and three patient care needs, and recognizing staff for their quantitative studies (two with control groups) have achievements. Finally, although the CNLs worked hard produced preliminary evidence correlating CNL imple- to ensure that the multidisciplinary team appreciated the mentation with improved outcomes (see Table 4). achievements of the staff nurses, it was hard to find the same recognition for their own work. They were Qualitative CNL Research repeatedly pulled in many different directions by Bombard et al. (2010) conducted an action research study clinicians that did not understand their role. Support to explore a cohort of four direct-entry master's student's from upper management was considered crucial to the CNL clinical immersion and postcertification transition success of their role; without it, they feared an uncertain experience. Participants used a variety of data collection future within their organization. Overall, the CNLs methods (see Table 2) and content analysis to identify expressed great pride in their work advocating for major themes defining the CNL transition experience. patients, but were concerned for their future as leaders The major theme was answering the question “What is a at the bedside, and felt they needed greater affirmation CNL,” which incorporated four subthemes: (a) coming to from their managers and leaders to sustain and/or the edge, (b) trusting the process, (c) rounding the continue to grow the role. corner, and (d) value becoming. The students struggled Stanton et al. (2011) examined the CNL role as to answer the question they were repeatedly asked by presently implemented to determine if the educational other clinicians during their immersion experience: What preparation of the CNL complements the implementation it was exactly that they were doing. It took a leap of faith of the role in the hospital, home health, and public health for each student to overcome the uncertainty of the arena. The investigators developed a questionnaire to clinical demands and to trust that they would meet gather respondent's agreement with 19 statements about clinical competencies by the end of the program. There CNL competencies and relationship to their current came a turning point for each student when they felt a clinical position. The questionnaire also contained open- sense of accomplishment in their actions and transitioned ended questions asking respondents “to describe and from uncertainty to confidence that they had the skills compare their actual role to the CNL as envisioned by the needed to improve patient processes. The students AACN.” Survey responses indicated a high degree of describe a process of continuing growth after graduation agreement with the nine components of CNL practice: and obtaining CNL certification to develop the clinical clinician, outcomes manager, client advocate, educator, expertise, experience, and self-assurance needed to feel at information manager, systems analysis/risk anticipator, a point of readiness to transition into a formal CNL role. team manager, member of a profession, and lifelong Sorbello (2010) used a hermeneutic phenomenological learner. No single respondent's clinical position incorpo- approach to explore the meaning of leadership for rated all nine, suggesting variability in the role depending practicing CNLs. Ten certified CNLs were interviewed on setting, which the investigators state conforms to the during the 2009 CNL Summit Conference to gather their description of expected role diversity within the AACN perspectives on the following: what it was like to be a White Paper. Qualitative analysis of open-ended ques- CNL; what it meant to lead at the point of care; and how tions resulted in the identification of four emerging caring was expressed in the CNL role. Emerging themes themes of CNL practice: (a) responsibility for outcomes of the meaning of leadership for CNLs practicing at the improvement, (b) use of evidence as a basis for practice, bedside were (a) navigating safe passage, (b) making a (c) importance of mentoring and developing staff, and CURRENT EVIDENCE BASE FOR THE CLINICAL NURSE LEADER 113

Table 1. Descriptions in the Literature of CNL (or Modified CNL) Implementations Within Various Health Care Systems Across the United States Healthcare Microsystem Context of Positive outcomes Report(s) describing setting setting(s) implementation described implementation 119-Bed academic 26-Bed No executive leadership Patient satisfaction scores, Bender, Mann, & Olsen, medical center progressive care involved; one CNL certified RN–physician team 2011, Bender, Connelly, in San Diego unit and others had BSN with communication and Glaser, & Brown, 2012, California “documented evidence of collaboration, staff Bender, Connelly, & nursing expertise and perceptions of a Brown, 2013 leadership” and “understanding collaborative environment [that] pursuit of CNL certification and advanced degree would be required” 551-Bed nonprofit 39-Bed diabetes/ AACN CNL White Paper Home health referral rates, Bowcutt, Wall, & University gastrointestinal served as a resource for the individual stories of Goolsby, 2006 Hospital in unit; cardiac unit “care coordinator” role, as “no patient-specific Augusta actual CNL program graduates positive outcomes Georgia yet existed.” Both care coordinators were NPs. Part of national pilot “to develop CNL curriculum as well as pilot the role within the organization” 5-Hospital, 1500- Approximately “Only experienced nurses Multidisciplinary rounds, Drenkard, 2004 bed Inova 40 units received team coordinator staff relationships, Health System throughout jobs. The level of education physician satisfaction in Fairfax the system that is ultimately decided Virginia upon for the CNL role will drive the experience level of the nurse in this role” 194-Bed for-profit 36-Bed CNL role superceded “patient Staff retention, patient and Gabuat, Hilton, Kinnaird, St. Lucie Medical progressive care care coordinator” role while physician satisfaction, Joint & Sherman, 2008, Center in St. unit; 45-bed coordinator responsibilities Commission core measures, Sherman, Edwards, Lucie Florida med–surg unit changed to more RNs with national Giovengo, & Hilton, 2009, administrative focus certification, HAPU Stanley et al., 2008, Hilton, 2010 4-Hospital 1100- 43-Bed med/ “Evaluations occurred in LOS, personal stories of Hartranft, Garcia, & Adams, bed nonprofit surg-telemetry settings in where CNL individual patient care 2007, Stanley et al., 2008 Morton Plant unit; 45-bed graduates and students were improvement, falls, CMS Mease Health oncology unit beginning to practice” core measures, HAPU, Care System in physician satisfaction Clearwater Florida VA Tennessee Ambulatory “All CNLs had master of Surgical infection rates, RN Fitzpatrick & Wallace, Valley surgery unit; science in nursing degrees hours per patient day, heart 2009; Harris, Walters, Healthcare surgical inpatient and had successfully passed failure-specific 30-day Quinn, Stanley, & McGuinn, System in unit; GI the CNL certification readmissions, Joint 2006; Hix, McKeon, & Nashville laboratory; examination” Commission core measures, Walters, 2009; Miller, 2008, Tennessee SICU; MICU; LOS, surgical and GI Ott et al., 2009 transitional care cancellation/no-show rates, unit postsurgery blood transfusion rates, ICU patient VTE prophylaxis, participation in restorative dining (if indicated) Veteran Health Med–surg, “VHA facilities with practicing Nursing hours per patient Ott et al., 2009 Administration subacute CNLS were invited to day, sitter utilization, care centers and SICU units participate in the evaluation falls, HAPU, CMS core (does not of the project”; does not measures (heart state exact specify education/certification failure discharge locations) teaching), VAP (Continued on next page) 114 MIRIAM BENDER

Table 1. (Continued) Healthcare Microsystem Context of Positive outcomes Report(s) describing setting setting(s) implementation described implementation Maine Medical Special care unit; CNL students assumed Ventilated patient LOS in Poulin-Tabor et al., 2008; Center in pediatric unit; responsibilities of role during ICU, individual stories Wiggins, 2006 Portland Maine cardiothoracic CNL immersion at the hospital of patient-specific unit; medical (present 5 days/week) positive outcomes cardiology unit Hunterdon Medical 3 med–surg “1 day per week to ‘play in the Improved collaborative Rusch & Bakewell-Sachs, Center in units role’ while in school.”“The professional relationships 2007 Flemington New CNL position with be part of Jersey the overall budget for FTEs” after graduation” Baptist Hospital in All units except Patient care facilitator role 11 a.m. discharge, CMS Sherman, Clark, & Miami Florida rehab, developed first, using BSN core measures, Maloney, 2008; Harris interventional degree RNs. The role “will patient satisfaction & Roussel, 2010 and diagnostic ultimately include both areas, PACU, advanced practice nurses and radiation CNLs” (11 PCFs have enrolled oncology in the educational program) OSF St Joseph 46-Bed med– “Patient care facilitator Falls, HAPU, patient Smith & Dabbs, 2007 Medical Center surg unit pilot, will transition into CNL” satisfaction, staff turnover, in Bloomington eventually all and are enrolled in a CNL LOS, discharges before Illinois units except program 11 a.m. obstetrics 321-Bed Flager 43-Bed cardiac/ “Patient care coordinator” role Nursing job satisfaction, Smith, Hagos, et al., 2006; hospital in St. pulmonary unit developed similar to CNL, nurse retention, patient Smith, Manfredi, Hagos, Augustine utilizing master's-prepared and physician satisfaction, Drummond-Huth, & Florida RNs. “Projected contract labor usage, Moore, 2006 implementation of the CNL LOS, restraint use, falls role” through partnership with NE Florida University 733-Bed nonprofit 17-Bed “CNL student's 3-month Pain management, nurse Stanley et al., 2008 Shands oncology unit immersion experience served response to call light and Jacksonville as the activity around which overall nursing care Academic Health the role was evaluated” patient satisfaction Center in Jacksonville Florida 336-Bed Virginia Extended LOS Role developed “drawing from LOS, letters of patient Tachibana & Nelson- Mason Medical patients (N6 days) definition of the CNL as care experiences Peterson, 2007 Center in Seattle throughout outlined by the AACN” and “a Washington the hospital nurse educated at the graduate level” St. Vincent Hospital “System service Clinical immersion served as Coordination of medication Stanton et al., 2008, in Birmingham line based, CNL project. “Students administration process for Lammon, Stanton, & Alabama implement care successfully completed the patients at risk for medical Blakney, 2010 management at CNL certification. CNLs [will] error the point of implement the role in their care” respective agencies” Alabama Dept of “All levels and State and community Stanton et al., 2008, Public Health aspects of the collaborative coordination Lammon, Stanton, & community” for pandemic influenza Blakney 2010 public health planning areas in Alabama Fayette Medical All patients at Tracking of patients Stanton et al., 2008, Center in risk for HAPU in throughout stay, protocol Lammon, Stanton, & Fayette Alabama a rural hospital education Blakney 2010 Alacare Home Stroke patients Patient/caregiver knowledge Stanton et al., 2008, Health and in the home care of disease management skills Lammon, Stanton, & Hospice in setting and functional status Blakney 2010 Birmingham Alabama CURRENT EVIDENCE BASE FOR THE CLINICAL NURSE LEADER 115

Table 1. (Continued) Healthcare Microsystem Context of Positive outcomes Report(s) describing setting setting(s) implementation described implementation Tuscaloosa VA SICU, MICU, VAP rates, compliance with Stanton et al., 2008, Medical Center CCU glycemic control protocol, Lammon, Stanton, & in Birmingham rapid response utilization, Blakney 2010 Alabama CRBSI rates LOS = length of stay, CMS = centers for medicare & medicaid services, VAP = ventilator associated pneumonia, BSN = bachelor of science in nursing, NP = nurse practitioner, HAPU = hospital-acquired pressure ulcers, ICU = intensive care unit, MICU = medical intensive care unit, SICU = surgical intensive care unit, CCU = coronary care unit, GI = gastrointestinal, VTE = venous thromboembolism prophylaxis, PACU = postanesthesia care unit, CRBSI = catheter-related blood stream infection.

(d) involvement in special organizational projects. The and (e) cautious about the future. CNLs described the investigators conclude that the CNL “travels well” and is continuous need to explain their role to other practi- adaptable to a wide variety of clinical microsystems and tioners, sometimes “at least 10 times each day.” They that evidence-based practice, outcomes management, and describe this as a result of inconsistent engagement from staff education are critical aspects of the role. executive leadership in the pilot project, causing Sherman (2008) used a grounded theory methodology confusion and role overlap for some of the CNLs within to explore factors that influenced the decisions of 10 chief their practice sites. Although the CNLs were clearly able nursing officers (CNOs) to promote involvement of their to articulate the value of their work, they also described organizations in the CNL project. Five major themes the constant challenges of staying focused on the role and emerged to form a framework explaining organizational not getting drawn into direct patient care because participation in the CNL project: (a) organization needs, managers or other leaders did not see the value of their (b) desire to improve patient care, (c) opportunity to work. This challenge to keep the role “pure” was also redesign care delivery, (d) promotion of professional recognized through the variation in CNL role implemen- development of nursing staff, and (e) potential to tation itself, depending on microsystem needs or enhance physician–nurse relationships. The CNOs de- organizational priorities. The CNLs felt that this lack of scribed the need for their organizations to do a better job consistent role delineation created role confusion and complying with regulatory requirements and viewed the was a barrier to wider acceptance. Overall, the CNLs felt CNL as way to ensure compliance at the point of practice. that no matter the challenges, their education had given They envisioned the CNL as an “air traffic controller” them a “phenomenal skill set” that made them invaluable who would reduce the chaos that is the current state of to organizations in a variety of positions (if not a formal clinical practice and help remedy undiagnosed systemic CNL role). CNLs who felt most successful in their role problems that showed up as adverse patient outcomes. had the greatest involvement of the CNO and unit They felt CNL leadership skills would be necessary to facilitate redesign of chaotic care delivery systems not functioning as needed to provide seamless patient care. Table 2. CNC Job Analysis Descriptive Statistics of Respondents' CNOs hoped the CNLs would help improve the image of Subdomain Weights nursing through mentoring, role modeling best practice, and encouraging professionalism at the bedside. Com- Subdomain Min % Max % Mean % munication was seen as essential to improving care Evidence-based practice 0 40 9.20 delivery, and CNOs predicted that the continuous CNL Interdisciplinary communication 0 30 8.15 presence on the unit would improve cross-disciplinary and collaboration skills communication. Overall, the investigator found that the Quality improvement 0 35 7.71 identified themes aligned well with the AACN vision for Integration of CNL role 0 20 6.64 the role and furthermore argued that this alignment of Illness and disease management 0 30 6.45 goals between education and practice may be a critical Team coordination 0 25 6.37 factor in the success of the CNL project. Lateral integration of care services 0 15 6.13 Advanced clinical assessment 0 15 5.99 Sherman (2010) also conducted an interpretive Health promotion and disease 0 20 5.96 phenomenology study to describe the role transition prevention management experiences of 71 CNLs as they pioneered the role in Horizontal leadership 0 20 5.79 diverse practice settings across the country. Certified Knowledge management 0 15 5.14 CNLs answered open-ended questions during semistruc- Ethics 0 84 5.10 tured telephone interviews. Interviews were taped, Healthcare advocacy 0 11 4.89 transcribed, coded, and categorized into emerging Healthcare systems 0 10 4.53 themes. Five major themes were identified regarding Healthcare informatics 0 20 4.29 the CNL role transition experience: (a) staying at the Healthcare finance and economics 0 10 4.07 bedside, (b) explaining who we are, (c) keeping things Healthcare policy 0 15 3.60 from falling through the cracks, (d) proving our value, Adapted from CNC, 2011, printed with permission from the CNC. 116 MIRIAM BENDER manager as champions of change during the implemen- the Tampa Bay Florida area. Staff nurses worked on tation phase. telemetry, urology, orthopedic, and medical–surgical Klich-Heartt (2010) explored entry-level master's CNL units employing CNLs or similar units that did not graduates utilization of end-of-program competencies in have CNLs. Staff nurses completed five survey instru- their current nursing practice through an investigator- ments: (a) Nursing Stress Scale (NSS) to measure work- developed “Entry-Level CNL” survey, which used CNL related nursing stress; (b) Nursing Work Related Index– end competencies as a source for items. The survey also Revised (WRS) to measure job satisfaction; (c) Medical included open-ended questions asking about CNL's Outcomes Inventory Study Short Form (MOI) to measure ability to apply elements of educational competencies in overall nurse well-being; (d) Anticipated Turnover Scale their daily practice. The survey was sent through Survey (ATS) to measure nursing turnover; and (e) an investi- Monkey in early 2010 to all recent graduates (n = 163) of gator-developed demographic survey. Independent t tests Sonoma State University and University of San Francisco and multiple regressions were used to analyze results. entry-level master's CNL programs. Fifty seven (35%) Major findings included a significant difference between graduates responded. Thirty-six percent were staff nurses groups on the “mental health” subscale of the MOI's and 40% were in “charge or leadership roles.” Overall, Mental Health Summary Score (t = −2.34, P = .021), more than half of the respondents felt they were able to indicating nurses working on a CNL unit were happier apply CNL competencies within their current nursing and less depressed than nurses not working on a CNL position, and 67% reported assimilating research-based unit. There was also a significant difference between evidence to improve their unit outcomes. Most were also groups on ATS score (t = 2.01, P = .047), indicating taking part in facility-wide committees and “having an nurses working on a CNL unit had less anticipated impact on client outcomes.” Common themes of open- turnover than nurses not working on a CNL unit. ended responses included the following: awareness of Regression analysis showed employment on a CNL unit their novice stage as a nurse; unfamiliarity or resistance to was associated with greater intention to stay on the unit the CNL role by their employers; and a realization of the (β = −2.5, P = .048). The R2 for the model was not potential for the CNL's skill set as their career advanced. provided, so it is unclear how much variation the model Moore and Leahy (2012) developed a “CNL Transi- accounted for. The investigator notes that the improved tions into Practice” questionnaire, which included 13 mental health of staff nurses working on CNL units may broad open-ended questions designed to explore CNL's be related to the social support the CNL provides as part experience implementing the role in their practice. The of their job workflow. The investigator also notes social survey was administered via Survey Monkey to 24 support has been linked to greater job motivation and certified CNLs currently practicing in the role (a date may explain why presence of a supportive CNL role was range was not provided). Qualitative content analysis was correlated with decreased anticipated turnover. The used to identify themes of CNL practice around the 13 investigator concludes that the CNL may be influential questions. For questions about role introduction, re- in reducing epidemic rates of nursing stress and turnover spondents were equally distributed in describing either a and should be further investigated. structured organizational rollout or a more ad hoc Bender et al. (2012) conducted a quasi-experimental practice introduction. For questions about role imple- interrupted time series study to measure patient satisfac- mentation, most respondents described a lack of role tion with multiple aspects of care 10 months before and clarity, and 43% described being clinically overburdened 12 months after integration of a CNL role on a because of this lack of role delineation. Overall, 82% progressive care unit, compared to a similar unit that believed that their role improved care quality while did not have CNLs. The setting was a 26-bed unit within remaining close to the bedside. Staff nurses, although a 119-bed academic medical center. Data were obtained appreciating the extra support, still did not understand from Press Ganey surveys, and analysis was completed what the role was about. For questions about role using a publicly available program for short time series sustainability, most respondents felt executive nursing data streams. CNL implementation was correlated with leadership would be essential to the role's continuing significantly improved patient satisfaction with admis- success, although a worrying 61% of respondents sion processes (r = +.63, P = .02) and nursing care (r = identified nurse administrators as having the greatest +.75, P = .003), including skill level (r = .83, P = .003), resistance to the role. Thirty-nine percent also identified and keeping patients informed (r = .70, P = .003), and the need for a more defined and structured role in order “attention to requests” (r = .68, P = .01). Control data for long-term sustainability. showed no significant changes in patient satisfaction measures throughout the study time frame. The in- Quantitative CNL Research vestigators note significant improvements in scores Kohler (2010) conducted an ex post facto study to corresponded with CNL accountability for care coordi- determine the relationship between the CNL role and (a) nation and interdisciplinary collaboration, but the work-related stress, (b) job satisfaction, (c) quality of life, introduction of multidisciplinary rounding and processes and (d) anticipated turnover of acute care staff nurses leading to better progression toward discharge goals did working on CNL and non-CNL units. Participants not impact patient satisfaction with their discharge or included 94 staff RNs from three nonprofit hospitals in their physician. The investigators conclude the data CURRENT EVIDENCE BASE FOR THE CLINICAL NURSE LEADER 117

Table 3. Qualitative Studies on the CNL Role Primary Study investigator purpose/aims Design Sample Data collection Analysis Major findings Sherman, Explore the Strauss and Corbin Convenience One-hour Coding, core Five major themes 2008 driving factors Grounded Theory sample of 10 (of semistructured categories emerged to form a that influenced a total of 25 face-to-face developed framework that the decisions invited to interviews using explains of CNOs to participate) 8 open-ended organizational promote the CNOs from questions participation in involvement health care CNL project. (a) of their agencies in organization needs, organizations Florida (b) desire to in the CNL participating in improve patient project the CNL project care, (c) opportunity to redesign care delivery, (d) promotion of professional development of nursing staff, (e) potential to enhance physician– nurse relationships Stanton, Examine the Exploratory survey Eight University Investigator- Frequency Overall findings Barnett, & CNL role as with closed and of Alabama CNL developed distributions of show there is Williams, it is presently open-ended graduates questionnaire closed-ended disparity between 2011 implemented responses (mailed with responses and the CNL role as and whether stamped return qualitative taught and how it is the educational envelope) content actually preparation with 19 analysis of implemented in any of the CNL statements open-ended particular setting. complements about the CNL responses Most respondents the implementation role asking for function as of the role in the respondent's educator, data hospital, home agreement analysis and health, and between effecting change in public health statement and organization. Most arenas their actual respondents were position not (or only description on a somewhat) 4-point Likert involved with care type scale. An coordination, unspecified financial impact number of open- analysis, or ethical ended questions guideline asking respondents development. “to describe and Themes from compare their open-ended actual role to responses include the CNL role as (a) responsibility envisioned by for outcomes the AACN” improvement, (b) use of evidence as a basis for practice, (c) importance of mentoring and developing staff, and (d) involvement in special organizational projects (Continued on next page) 118 MIRIAM BENDER

Table 3. (Continued) Primary Study investigator purpose/aims Design Sample Data collection Analysis Major findings Bombard Analyze the Action research as Four students, Reflective Content Dominant theme: et al., 2010 experience described by clinical faculty journals, faculty analysis, theme how to answer the of direct Holter and leader, writing notes of seminar development question “what is a entry master's Schwartz-Barcott consultant discussions, CNL.” Subthemes students in the student reflections include: coming to first cohort to on experience the edge, trusting complete the written after the process, CNL curriculum graduation, rounding the and sit for CNL transcripts of 4 corner, value certification analytic discussion becoming sessions Sherman, Describe the Interpretive 71 certified Semistructured Open coding Themes explaining 2010 role transition phenomenology CNLs telephone into categories the CNL role experiences nationwide interviews with and themes transition of 71 CNLs as working in the 9 open-ended experience they pioneered role in practice questions included: (a) staying the role in settings at the bedside, (b) practice settings explaining who we are, (c) keeping things from falling through the cracks, (d) proving our value, and (e) cautious about the future Sorbello, What is the Van Manen's 10 certified 60-Minute “selective or Essential themes 2010 meaning of phenomenology CNLS that unstructured highlighted of meaning that leadership as approach responded to (using “story reading” leading at the experienced by email invitations method”) approach as bedside has for CNLs? What is for participation interviews with defined by Van CNLs include: it like to be a during the 8 in-person and Manen to form (a) navigating safe CNL; what does national CNL 2 over-the- thematic passage, (b) making it mean to lead Conference in phone; field groups a difference evokes at the point of New Orleans, notes, pride, (c) bringing care; how is Louisiana investigator the bedside point caring lived in journal of view, (d) the role of the knowing the CNL? patient as caring person, (e) living caring with nurses, and (f) needing to be known, understood and affirmed Moore & Explore the Qualitative, 24 certified 24-Item Qualitative Themes for Leahy, experiences of descriptive design CNLs identified Investigator- content implementing the 2012 CNLs as they through developed “CNL analysis new CNL role launched the attendance list Transition into included: (a) CNL role in the of 2009 CNL Practice systematic vs. practice setting Summit Questionnaire,” unplanned role Conference broad open- introduction, (b) ended questions lack of role clarity developed and overburdened through review practice, (c) of literature and improved care CNL-educator quality, and (d) need expertise for nurse leader support and more structured role description CURRENT EVIDENCE BASE FOR THE CLINICAL NURSE LEADER 119

Table 3. (Continued) Primary Study investigator purpose/aims Design Sample Data collection Analysis Major findings Klich-Heartt, Evaluate entry- Descriptive 57 recent 11-Item (plus Descriptive 40% in charge/ 2010 level master's survey design graduates from demographic frequencies leadership roles; CNL graduates Sonoma State questions) and review majority used with the CNL University and investigator plus coding of aggregate data to end-of-program University of San developed open-ended improve patient competencies to Francisco entry- “entry-level question to care and part of determine level master's CNL” survey, identify common facility-wide whether these program in including 1 themes committees; graduates are nursing open-ended 55% applied able to have question, using competencies to positive effects end-of-program their current role. on patient, competencies as Qualitative themes systems and source for items include (a) leadership administered knowledge that still outcomes in February 2010 a novice, (b) clinical settings unfamiliarity/ resistance to CNL, and (c) realize potential of skill set in the future correlating CNL-mediated care processes with improved size of the outcomes as well. The main relevant quantified patient satisfaction show the CNL may be an innovative finding was a significant positive relationship between strategy for restructuring care delivery structures and transformational leadership style of the CNL and staff services to improve care quality. RN's self-rating of leadership “consideration” behaviors Guillory (2011) conducted a cross-sectional correla- (β = .340, P = .002). The investigator concludes the data tion study to examine (a) the relationship between the support prior research showing positive relationships leadership style of nurse managers and the leadership between transformational leadership style of clinical and style of their CNLs, (b) the relationship between the administrative leaders, such as a CNL, and staff RN leadership style of CNLs and the leadership behaviors of performance and behavior. staff nurses, and (c) if differences exist in staff nurse leadership behaviors as a function of nurse manager level Discussion of engagement. Participants included 180 RNs and 18 The CNL has been piloted in over 159 health care CNLs working at various clinic locations in the Houston organizations across the country through partnerships Texas area. Staff nurses and CNLs completed a survey with more than 91 schools of nursing (Stanhope & containing three instruments: (a) Multifactor Leadership Turner, 2006). There are 25 reports describing the Questionnaire (MLQ-5x short) to measure leadership context of implementation and/or quality improvements styles; (b) Leadership Behavior Description Question- facilitated through CNL integration into various care naire (LBDQ-XII-self) to measure leadership behaviors; settings. Most microsystems were within acute care and (c) an investigator-developed demographic survey. facilities, but the role is promoted to be valuable across CNLs completed the MLQ-5x “Rater” form to rate their the care spectrum. A recent job analysis validated manager's leadership style, and the MLQ-5x “Leader” essential CNL tasks, knowledge, and skills needed for form to rate their own leadership style. Staff RNs competent CNL practice and were reflected in many of completed the MLQ-5x Rater from to rate their CNL's the CNL processes described in the CNL implementation leadership style, and the LBDQ-XII-self form to measure reports, such as responsibility for quality improvement their own leadership behaviors. The survey data were projects, encouraging interdisciplinary communication analyzed using regression analyses, cluster analysis, and t and collaboration, and initiating evidence-based guide- tests. A major limitation of this study is that not all stated lines to better provide and coordinate safe and effective results are quantified either in the text or within tables, so patient care. it is impossible to corroborate statements such as “there Although the results of the implementation reports are was a significant, positive relationship between the CNL's very encouraging, one must be careful interpreting leadership style and staff RN's rating on structure overall significance as all used either a narrative or case [leadership behavior].” In addition, although regression study approach, which makes it difficult to separate CNL model summary data are presented for all analyses, the impact from the influence of other non-CNL processes investigator does not include coefficient tables with occurring simultaneously on the unit or throughout the confidence intervals, so it is difficult to gauge the effect organization. Many outcomes were apparently chosen 120 MIRIAM BENDER

Table 4. Quantitative Studies on the CNL Role Primary investigator Study purpose/aims Design Sample Measures Analysis Major findings Kohler Explore the relationship Prospective Ex 94 RNs from 3 (a) NSS Independent Mental health (2010) of the CNL role with post facto nonprofit (b) WRS t tests and subscale (of (a) work related stress, hospitals in the (c) MOI multiple mental health (b) job satisfaction, Tampa Bay (d) ATS regression summary score) (c) quality of life, and Florida area. was significantly (d) anticipated turnover Units include different between of acute care nurses. tele, urology, groups. In addition, this research ortho, and Significant examined the med-surg difference between interrelationships among employing groups on ATS work-related stress, CNLs and scores. Regression quality of life, job nonequivalent analysis showed satisfaction, and control units employment on anticipated turnover CNL-unit and WRS score predicted ATS score. Guillory Examine (a) the Cross-section 198 RNs (180) (s) Multifactor Regression Leadership styles of (2011) relationship between the correlation and CNLs (18) Leadership analysis, CNLs (as perceived leadership style of nurse design at various Questionnaire hierarchical by staff nurses) managers and the Kelsy-Seybold (MLQ-5x short) cluster predicted leadership leadership style of their Clinic locations (b) Leadership analysis, behaviors of staff CNLs, (b) the relationship in the Houston Behavior t tests nurses. between the leadership Texas area Description Leadership styles of style of CNLs and the Questionnaire nurse managers (as leadership behaviors of (LBDQ-XII-self) perceived by CNLs) staff nurses, and (c) see predicted the if differences exist in staff leadership styles nurse leadership behaviors of CNLs. as a function of nurse manager level of engagement Bender Assess the impact of CNL Short 36-Bed Press-Ganey Simulation CNL (2012) integration into an acute interrupted progressive survey scores: modeling implementation was care microsystem on care time series care unit and a “admission”, analysis for correlated with quality as measured by nonequivalent “discharge”, short time significantly patient satisfaction with control “nursing”, series data improved patient care oncology-BMT “physician”, streams satisfaction with unit located “skill of the “admission,” within a 119- RN”, “RN kept “nursing”, including bed academic you informed”, “skill of the RN”, “RN medical center “attention to kept you informed”, in San Diego special needs”, “attention to special California “attention to needs”, “attention to requests” requests”. There was no significant correlation with improved patient satisfaction and control data.

because of CNL-developed projects specifically targeting negative or neutral outcomes cannot be compared with them. These targeted outcomes could arguably have been the published evidence to produce a more comprehensive accomplished by clinicians other than CNLs; for picture of the CNL in practice, including facilitators and example, through a unit-based, staff nurse-led quality barriers to effective implementation and/or sustainability. improvement project. Publication bias, or the possibility There were seven qualitative and survey studies found of unpublished CNL pilot interventions that may not in the literature regarding the CNL role. Most explored have resulted in care quality improvements, must also be the transition experience of CNL cohorts pioneering the considered when interpreting these reports: Unpublished educational and clinical pathways leading to a formal CURRENT EVIDENCE BASE FOR THE CLINICAL NURSE LEADER 121

CNL role in an organizational setting. Common themes These outcomes also need to be linked to CNL-specific found across studies included the challenges CNLs felt practice components. This will require the development explaining the CNL role to themselves and others; of valid instruments capable of measuring CNL-mediated keeping patients safe; mentoring nurses through role contributions to care outcomes. modeling; the necessity of organizational leadership Qualitative research conducted on the CNL empha- support for implementation success; pride in staying at sizes the variation of the role across settings. CNLs feel the bedside; and uncertainty about the future of the CNL. uncertain about clarifying their role and sustaining it in Uncertainty was related to the disparate ways the role has the future because of the general ambiguity surrounding been operationalized in various care settings, and the lack the role and its function within the care delivery setting. of role clarity highlighted in many of the studies. Notably, This ambiguity highlights the need for research that can “integration of the CNL role” was listed as the fourth help articulate the role in practice and identify essential most important CNL practice subdomain as defined by CNL practice elements and activities. Without a clear certified CNLs in the recently completed CNL job model for practice, CNLs will continue to struggle to analysis (see Table 2), substantiating the challenges define and articulate their value. inherent in effectively defining and operationalizing the role. Where the role has met with success, executive Conclusions leadership was viewed as essential to that success. Leaders that stood behind the role viewed the CNL as a The CNL has been touted as an unprecedented partner- way to elevate the professional status of nurses within an ship between academia and practice to both educate the interdisciplinary care team and envisioned the CNL as new breed of nurse leader and redesign the environment the point person at the bedside ensuring compliant and in which this leader would practice (Porter-O'Grady, quality care. Clark, & Wiggins, 2010; Stanley, Hoiting, Burton, Harris, There were only three quantitative research studies & Norman, 2007). The IOM Future of Nursing report found in the literature on the CNL role. None were (2010) highlights the CNL role as a nursing-led designed to specifically define or measure CNL-specific innovative strategy for restructuring care delivery settings mechanisms of action that resulted in targeted outcomes. and services to improve care quality. This review has All three were correlational studies, and only two used summarized the literature on CNL implementations control groups. In these studies, CNL integration into across the country and the research completed to-date care delivery settings was correlated with the following: on the CNL. All CNL implementation reports and studies happier staff nurses; decreased anticipated staff RN describe improved care quality outcomes after introduc- turnover; improved patient satisfaction with nursing tion of the role into a care delivery microsystem, care and admission processes; and greater staff RN self- providing preliminary evidence supporting the capacity report of leadership behaviors. Each study had method- of the CNL to reliably improve care quality wherever the ological limitations, such as small sample size, non- role is implemented. A consistent finding across reports equivalent (or no) control groups, and incomplete data was that CNLs are still struggling to define the role to reporting, which limit generalizability of the results. themselves and to the health care spectrum at large. Nevertheless, the combined quantitative trends appear to While the AACN CNL White Paper provides a concise show an improvement in staff RN and patient satisfaction model for CNL educational curriculum and end compe- with their care environment when a CNL is integrated tencies, there is a compelling need for further research to into that environment. substantively delineate the CNL role in practice, describe care delivery structures and processes that influence CNL Recommendations for Future Research integration, and develop indicators capable of capturing To date, all published reports on CNL implementation CNL-specific contributions to improved care quality. describe, in various detail and rigor, a diverse list of improved quality outcomes after introduction of the CNL References depending on CNL activities and microsystem priorities. American Association of Colleges of Nursing. (2007). AACN Still, little is known about care delivery structures and White Paper on the education and role of the clinical nurse leader. processes that influence successful CNL integration, and Retrieved January 2010 from, http://aacn.nche.edu/publications/ components that either facilitate or hinder CNL effec- whitepapers/clinicalnurseleader07.pdf. tiveness and sustainability. Bartels, J., & Bednash, G. (2005). Answering the call for Research on the CNL role is still in its infancy, with quality nursing care and patient safety: A new model for nursing – only a handful of studies to look to for evidence of CNL- education. Nursing Administration Quarterly, 29,5 13. specific impact on patient outcomes. Quantitative Bender, M., Connelly, C. D., & Brown, C. (2013). Interdis- ciplinary collaboration: The role of the clinical nurse leader. research focused on correlating CNL practice in general Journal of Nursing Management, 21, 165–174, http://dx.doi.org/ with improvements in patient and staff outcomes. 10.1111/j.1365-2834.2012.01385.x. Further research is needed to quantify CNL impact on a Bender, M., Mann, L., & Olsen, J. (2011). Clinical nurse wider range of health outcomes, including overall leader. Leading transformation: Implementing the clinical nurse microsystem health, interdisciplinary teamwork, and leader role. Journal of Nursing Administration, 41, 296–298, patient care coordination within and across settings. http://dx.doi.org/10.1097/NNA.0b013e3182250905. 122 MIRIAM BENDER

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