The Clinical Nurse Leader

Quarterly scientific, online publication by Department of Nursing A’, Technological Educational Institute of Athens

_REVIEW_

The clinical nurse leader

Theodosios Stavrianopoulos

RN, Bsc, Msc, General Hospital of Pyrgos Ilia, Greece

ABSTRACT Background: The Clinical Nurse Leader (CNL) is the first new role in nursing since the nurse practitioner was introduced over many years ago. The CNL evolved after the American Association of Colleges of Nursing (AACN) convened a task force to identify ways to improve quality of patient care and determine how to prepare nurses with the skills and competencies needed to thrive in the current and future healthcare system. The original task force on education developed models for nursing education and regulation. A second task force was established, and from that work, a new role emerged-the Clinical Nurse Leader (CNL). Aim: The aim of the present study was review the literature about the role of Clinical Nurse Leader. Method and Material: Method was used is to search in databases (PUBMED, SCOPUS) to identify articles related to the role of clinical nurse leader. The search took place in February 2011 for scientific papers until February 2011. The keywords used in combination were: clinical, nurse, leader, leadership. Results: The Clinical Nurse Leader role was developed in response to concerns about the quality and safety of nursing care in the complex, technologically advanced, ever-changing healthcare system. The CNL could be a clinician, an advanced generalist, an outcomes manager, an interdisciplinary care team manager, a patient advocate, an educator, an information manager, a member of the profession and a lifelong learner. Conclusions: The Clinical Nurse Leader role emerged following several years of research and discussion with stakeholders as a way to engage highly skilled clinicians in outcomes-based practice and quality improvement strategies. The CNL is an advanced generalist clinician with education at the master's degree level. The Clinical Nurse Leader is an emerging nursing role developed by the American Association of Colleges of Nursing (AACN) in collaboration with an array of leaders from the practice environment. Two AACN task forces were convened to identify a) how to improve the quality of patient care and b) how to best prepare nurses with the competencies needed to thrive in the current and future health care system.

Key words: Clinical, nurse, leader, leadership.

CORRESPONDING AUTHOR Stavrianopoulos Theodosios 4 Archimidous Street P.C: 27100. Pyrgos Ilias, Greece Email: [email protected]

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Volume 6, Issue 3 (July – September 2012) INTRODUCTION wenty-first century realities pacifying, and challenging are all part of T affecting healthcare are dramatically a day’s work.4 and radically changing the landscape for The Clinical Nurse Leader (CNL) is the nursing practice.1 Much of the intensive first new role in nursing since the nurse and comprehensive professional and role practitioner was introduced over many development for the entire field of years ago. The CNL evolved after the nursing grew out of the focused action of American Association of Colleges of nursing leaders during the 20th century.2 Nursing (AACN) convened a task force A clinical nurse is certainly one involved to identify ways to improve quality of in clinical practice with knowledge, patient care and determine how to experience and understanding of prepare nurses with the skills and providing nursing care. Leadership competencies needed to thrive in the implies authority in the broadest sense of current and future healthcare system. the word, is nonhierarchical and not The original task force on education confined to a specific set of skills, developed models for nursing education attributes or traits. One can deduce, and regulation. A second task force was then, that clinical nursing leadership established, and from that work, a new reflects all of the complexity of the role emerged - the CNL. The role is culture, the organization, the practice prepared in a new master of nursing setting and situational variables of each curriculum that educates nurses to clinical nurse leader.3 understand how to provide care and Clinical leadership requires dedication. improve quality in today's complex Clinicians are being asked to respond to healthcare system. a range of challenges: investment is The coursework provides theoretical and slowing down, and demands for quality, clinical experiences that result in safety, and efficiency are rising. Strategic competencies that prepare the CNL to be plans from health authorities and trusts a strong leader and clinician in today's are identifying key areas for service healthcare setting. CNLs are putting a redesign and improvement. Clinical new face on nursing as a true partner in leaders are standing in the gap between care with colleagues across the management and their clinical healthcare system by acting as an colleagues-enthusing, negotiating, integrator of the threads of care provided

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E-ISSN: 1791-809X Health Science Journal © All rights reserved www.hsj.gr Quarterly scientific, online publication by Department of Nursing A’, Technological Educational Institute of Athens by many to weave a new fabric of comprehensive, coordinated care. Nurses Results have always been patient advocates and The Clinical Nurse Leader Role. did what needed to be done for patients, The CNLs working in partnership with no matter what the circumstances or clinical nurses, physicians, other allied environment in which they practiced. health professionals, and the patients Today, nursing is called upon to rise and families are strengthening patient- above the staccato pace of fragmented centered care through a team approach. and complex healthcare delivery, as well Leading processes of care, the CNLs are as partner with, others to ensure that able to synthesize best practices from all patient care is safe and effective. The disciplines and reach improved outcomes CNL is a fresh new role that is helping to on patients’ behalf while breaking down answer this call and holds great promise discipline-centric silos.5 The Clinical for the future in a time when it is Nurse Leader (CNL) role was developed desperately needed.5 in response to concerns about the quality and safety of nursing care in the Aim complex, technologically advanced, ever- The aim of the present study was review changing healthcare system.6 As a the literature about the role of Clinical master’s prepared nurse, the CNL is Nurse Leader (CNL). educationally prepared as an advanced nurse generalist to improve patient care Material and Methods outcomes through use of the Method was used is to search in microsystem assessment process7 and databases (PUBMED, SCOPUS) to managing care delivery for a group of identify articles related to the role of patients.7-9 clinical nurse leader. The search took As a clinician, the CNL would use place in February 2011 for scientific evidence-based information to design papers until February 2011. The and coordinate the care delivered to keywords used in combination were: individuals and cohorts of patients clinical, nurse, leader, leadership. We within the rural hospital microsystem. found a total of 378 articles. In this Through the lateral integration of care, literature review were included twenty the CNL can facilitate and coordinate five articles that were deemed absolutely multiple disciplines and services to on the subject. ensure the most efficient and goal-

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Volume 6, Issue 3 (July – September 2012) directed activities are performed at the evaluates patient health and nursing care right time and in partnership with other process outcomes through the analysis disciplines.10 Reduced fragmentation of of variance data, communicates findings care and gaps in communication result in to the healthcare team, and leads the cost-effective efficiency, improved team in the implementation of initiatives clinical outcomes, and increased patient to treat deficiencies within the satisfaction. microsystem. Cost benefit analysis is As an advanced generalist with graduate- used as a strategy to reduce waste and level nursing knowledge of illness and manage resources. The organizational disease management, health assessment, effectiveness of the CNL is measured by and innovative nursing interventions, improved clinical, financial, and the CNL bring nursing leadership needed satisfaction outcomes.12 Examples of at the point of care to ensure high CNL effectiveness in improving clinical quality, safe generalist nursing care. outcomes include improved rates of Comprehensive knowledge of the patient home health referrals, discharge and case management skills, allows the planning13 improved core measure data, CNL to facilitate patient movement decreased nursing staff turnover14, efficiently through the rural healthcare reduced length of stay (LOS)15 increased system from the period of acute illness to patient satisfaction, a reduction in fall the patient’s return to the community. rates, and fewer cardiac arrests.16 Efficiency and effectiveness in care Satisfaction outcomes include not only delivery is particularly important in patient satisfaction but nursing staff Critical Access Hospitals (CAH) with satisfaction which is demonstrated by programmatic requirements to limit the increased retention rates, empowerment length of stay to 96 hours and inpatient of nursing staff, and participation in census no more than twenty five career advancement opportunities. inpatients.11 As the interdisciplinary care team As an outcomes manager, the CNL is manager, the CNL delegates and prepared to lead quality improvement manages nursing team resources (staff initiatives and design research-based and supplies).17 Through an interventions that reduce error, increase understanding of human interactions, patient safety, and stream-line communication, problem-solving skills, healthcare delivery processes. The CNL conflict management, and coalition or

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E-ISSN: 1791-809X Health Science Journal © All rights reserved www.hsj.gr Quarterly scientific, online publication by Department of Nursing A’, Technological Educational Institute of Athens team building18 the CNL is able to practice, critical thinking, and sound advance patient-care delivery through clinical decision-making. effective team work. As an information manager, the CNL is As a patient advocate, the CNL leads able to use information systems and efforts to create and manage a care technology that put knowledge at the environment that is responsive to the point of care to improve healthcare healthcare needs of diverse rural patients outcomes familiarity with the facility’s and families. The CNL can include state of technology and information patient preferences and values into the systems allows the CNL to identify and plan of care with patients and families document internal trends, as well as included as partners in care and compare microsystem function to decision-making. Through analysis of external benchmarks. As a systems differences in clinical outcomes for analyst/risk anticipator, the CNL cohorts of patients in the microsystem, participates in the review and evaluation the CNL is able to address health of processes at the system and individual disparities for the most vulnerable level to anticipate risks to patient safety, including the uninsured, the aged, the prevent medical error, and improve the less educated, and those with cultural quality of patient care delivery.17 barriers. As an advocate for health care Utilizing tools such as the Failure Mode professionals, the CNL promotes Effect Analysis (FMEA) and Root Cause practices that are characteristic of Analysis (RCA) allow the CNL to healthy work environments. anticipate and respond appropriately to As an educator, the CNL prepares near misses and sentinel events.18 individuals, families, or cohorts of clients As a member of a profession, the CNL is for self-care and a maximal level of personally accountable for her/his functioning and wellness.17 To maximize personal practice; actively engaging in wellness, health promotion, and risk the acquisition of knowledge and skills reduction, education programs are to effect change in health care practice designed and implemented, with and outcomes and in the profession.17 particular emphasis on those with As a lifelong learner, the CNL recognizes chronic illnesses. The CNL working at the need to actively pursue new the point of care in the microsystem is knowledge and skills as the practice roles able to mentor new members of the and the health care system evolve.19 nursing staff, promoting evidence-based

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Volume 6, Issue 3 (July – September 2012) Discussion which we do not have enough staff to fill The CNL is a generalist clinician with existing positions, that we are discussing education at the master’s degree level. the creation of another nursing role. This nurse leader must be prepared to However, there are those who would bring a high level of clinical competence emphatically state that it is exactly the and knowledge to the point of care and convergence of these and other internal to serve as a resource for the clinical and external factors that provide an nursing team.20 It is supported that opportune time for the development of a clinical nurse leaders have the new provider of nursing care. Clinical opportunity to work effectively and leaders in nursing may feel stuck in the efficiently through collaboration, middle of conflicting demands from the evaluating the present roles, and various members of their organisation developing a strategy of continual review and patients' needs.23 Nurse executives of the roles that best fit the institution, face daily struggles in their attempts to the staff, and, ultimately, the patient.21 staff clinical units with competent, As the conceptual framework of the task qualified registered nurses who are force moves into our practice settings, accountable for a full range of patient challenges and issues arise that will need interventions and associated practice to be addressed, the CNL role holds outcomes. Our current work much promise, albeit with many environments are fraught with numerous unanswered questions. The role of the challenges that affect the quality, safety, nurse executive will be to serve as a and effectiveness of patient care. leader of the change process, helping High staff vacancy and turnover rates resolve the unanswered questions, reflect the growing level of frustration of participating actively in the dialogue bedside caregivers. A compelling case with their academic partners, and can be made for a generalist clinician leading the way by experimenting and prepared at the master’s level to help implementing new models of care. As focus on and promote the clinical, nurse executives direct the path to financial, utilization, and quality implementation, several areas of elements of the day-to-day practice of questions require explorations.22 the staff nurse. The potential for both Additionally, it appears ironic amid our duplication and fragmentation of care current nursing shortage, a situation in poses additional challenges to addressing

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E-ISSN: 1791-809X Health Science Journal © All rights reserved www.hsj.gr Quarterly scientific, online publication by Department of Nursing A’, Technological Educational Institute of Athens role clarity and practice differentiation. care outcomes. In addition, the The ultimate success of the CNL will be experiences of these three settings dependent on the design of the position demonstrate significant cost savings in and its application at the patient’s very short periods of time. Similar bedside. During implementation, role outcomes are also being reported at clarity between the CNL and other other sites across the country.24 Clinical advanced practice nurses must be nurse leaders can be seen as experts in defined. The potential for duplication their field, and because they are and confusion of role sets must be approachable and are effective minimized in the current environment of communicators, are empowered to act as cost containment. Although the concept a role model, motivating others by of the CNL role may not be perfected matching their values and beliefs about yet, it offers the opportunity for dialogue nursing and care to their practice. This is among our colleagues in academia and supported by a new leadership theory, service - a dialogue that is critical to its congruent leadership, proposed as the successful implementation.22 most appropriate leadership theory to While it is tempting to suggest a direct support an understanding of clinical relationship between the implementation leadership. of the CNL role and changes in outcome Clinical nurse leaders are followed measures, the primary value of because there is a match between the examining early outcomes experienced leader's values and beliefs and their by first adopters of the CNL role is to actions.25 Working together as a raise awareness of the potential for community of nurse leaders will be improved outcomes of care and cost essential to the success of this or any savings. In addition, it stresses the need other innovative attempt to change the to compare findings of outcomes from practice of nursing in our care settings. multiple sites. The creation of the CNL Identifying stakeholders with the Evaluation Plan is needed to learn more influence and courage to initiate the about what CNLs do and their impact on necessary changes to nursing practice is patient outcomes in diverse health care a key first step. Nursing associations, units and with different patient practice partners, academic institutions, populations. Early evaluation efforts like and providers of healthcare must all be these provide glimpses into the potential willing to come to the table to participate the CNL role holds for improving patient in this effort. Leaders in nursing must be

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Volume 6, Issue 3 (July – September 2012) willing to create spaces for dialogue and advanced generalist clinician with decision making. We may all not agree education at the master's degree level. on the details of the CNL role or even Graduate education is necessary because the fact that we need one. But we must the CNL must bring a high level of all engage in the conversation in an clinical competence and knowledge to effort to find solutions. By considering the point of care and to serve as a the proposal and the subsequent pilot resource for the nursing team. The programs as a “work in progress,” master’s degree with a major in nursing nursing as a discipline will learn to be will prepare graduates for an advanced more comfortable living with the generalist role. ambiguity and uncertainty as we The CNL provides and manages care at systematically and scientifically find a the point of care to individuals, clinical better way to serve our patients. populations and communities. In this role, the CNL is responsible for the Conclusions clinical management of comprehensive The Clinical Nurse Leader is an emerging client care, for individuals and clinical nursing role developed by the American populations, along the continuum of Association of Colleges of Nursing care and in multiple settings, including (AACN) in collaboration with an array of virtual settings. The CNL is responsible leaders from the practice environment. for planning a patient’s contact with the Two AACN task forces were convened to health care system. The CNL also is identify: responsible for the coordination and - How to improve the quality of patient planning of team activities and care and functions. In order to impact care, the - How to best prepare nurses with the CNL has the knowledge and authority to competencies needed to thrive in the delegate tasks to other health care current and future health care system. personnel, as well as supervise and The Clinical Nurse Leader role emerged evaluate these personnel and the following several years of research and outcomes of care. Along with the discussion with stakeholders as a way to authority, autonomy and initiative to engage highly skilled clinicians in design and implement care, the CNL is outcomes-based practice and quality accountable for improving individual improvement strategies. The CNL is an

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