The Clinical Nurse Leader: a Catalyst for Improving Quality and Patient Safety

Journal of Nursing Management, 2008, 16, 614–622

The clinical nurse leader: a catalyst for improving quality and patient safety

1 2 3 JOAN M. STANLEY PhD, CRNP, FAAN , JANE GANNON DNP, RN, CNM , JESSE GABUAT MSN, RN ,SUSAN 4 5 6 HARTRANFT MS, ARNP, CNL , NANCY ADAMS MS, RN, CNL , CHRISTY MAYES MS, RN, CNL ,GINAM. 7 8 9 SHOUSE MSN, CMSRN, CNL , BARBARA A. EDWARDS BSN, CMSRN and DANITA BURCH MSN, RN, CNL 1Senior Director of Education Policy, American Association of Colleges of Nursing, Washington, DC, 2Assistant Clinical Professor, College of Nursing, University of Florida (UF), Jacksonville, FL, 3Director, General Medical/ Surgical and Orthopedic/Neurology Departments, St Lucie Medical Center, Port St Lucie, FL, 4Coordinator of Nursing Research, Morton-Plant Mease, Clearwater, FL, 5Clinical Nurse Leader, Morton-Plant Mease, Clearwater, FL, 6Clinical Nurse Leader, Morton-Plant Mease, Clearwater, FL, 7Clinical Nurse Leader, St Lucie Medical Center, Port St Lucie, FL, 8Clinical Nurse Leader Student, St Lucie Medical Center, Port St Lucie, FL and 9Clinical Nurse Leader, Shands Jacksonville, Jacksonville, FL, USA

Correspondence STANLEY J.M., GANNON J., GABUAT J., HARTRANFT S., ADAMS N., MAYES C., SHOUSE G.M., Joan M. Stanley EDWARDS B.A. & BURCH D. (2008) Journal of Nursing Management 16, 614–622 AACN The clinical nurse leader: a catalyst for improving quality and patient safety One Dupont Circle NW Suite 530 Aim The clinical nurse leader (CNL) is a new nursing role introduced by the Washington American Association of Colleges of Nursing (AACN). This paper describes its DC 20036 potential impact in practice. USA Background Signiﬁcant pressures are being placed on health care delivery systems to E-mail: [email protected] improve patient care outcomes and lower costs in an environment of diminishing resources. Method A naturalistic approach is used to evaluate the impact the CNL has had on outcomes of care. Case studies describe the CNL implementation experiences at three different practice settings within the same geographic region. Results Cost savings, including improvement on Centers for Medicare and Medic- aid Services (CMS) core measures, are realized quickly in settings where the CNL role has been integrated into the care delivery model. Conclusions With the growing calls for improved outcomes and more cost-effective care, the CNL role provides an opportunity for nursing to lead innovation by maximizing health care quality while minimizing costs. Implications for nursing management Nursing is in a unique position to address problems that plague the nationÕs health system. The CNL represents an exciting and promising opportunity for nursing to take a leadership role, in collaboration with multiple practice partners, and implement quality improvement and patient safety initiatives across all health care settings. Keywords: clinical nurse leader, microsystems of care, patient safety, pay-for-performance, quality improvement

Accepted for publication: 25 March 2008

DOI: 10.1111/j.1365-2834.2008.00899.x 614 ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd The clinical nurse leader

comes, and innovation. Within each domain, a set of Introduction possible metrics are identified, which could be mea- In 2004, 78 schools of nursing with multiple and diverse sured by data already being collected by most health practice partners responded to an invitation sent by the care settings. In 2006, the CNL Scorecard was piloted American Association of Colleges of Nursing (AACN) at TennValley Inc. over a 3-month period on several to join a national initiative to develop a masterÕs cur- units where a CNL had practised for at least riculum to prepare graduates with the set of compe- 6 months. The purpose of the pilot was to test the tencies, skills and knowledge delineated in the AACN definitions, data collection processes and analyses. In white paper titled The Education and Role of the this brief 3-month period, positive patient care out- Clinical Nurse Leader (2007). These education-practice comes were observed, including a decrease in read- partnerships were also challenged to transform one or mission rates and decreased length of stay for heart more units within the health care setting to integrate the failure patients, decreased patient falls, and decreased CNL role into the care delivery model. Since that time, post-surgical infection rates (Harris et al. 2006). Fol- the number of partnerships engaged in the initiative has lowing the pilot, education-practice partners were grown to include 92 schools with 192 health care asked to replicate the evaluation in health care settings institutions. The practice sites are primarily acute care where CNL graduates and students were beginning facilities but also include school health departments, to practise. The goal of these evaluation efforts was to visiting nurses associations, public health agencies, and expand data collection and comparison of findings to long-term care and rehabilitation facilities. additional and diverse sites and over extended periods In autumn 2006, the first CNLs graduated from 12 of time. This paper describes some evaluation efforts masterÕs nursing programmes. These graduates repre- to date in three different practice sites. sented both post-baccalaureate nursing masterÕs programmes and second degree or generic masterÕs degree Background of the need for a new health care programmes1. The CNL Certification examination, professional developed by AACN and first administered in autumn 2006, created a unique credential for graduates of the Over the past decade, reports from the Institute of CNL programmes. The CNL credential, a registered Medicine (2000), the Joint Commission on Accredita- trademark, indicates the individual has met a national tion of Healthcare Organizations. (2002) and the standard of requisite knowledge and experiences, American Hospital Association Commission on Work- including graduation from a masterÕs programme that force for Hospitals and Health Systems (2002) have prepares him/her with the CNL competencies, has had described the USÕs health care system as broken and in specific required clinical experiences, and has practised serious need of repair. Other reports (Institute of in the CNL role in a formal clinical immersion experi- Medicine 2001, 2004) have stressed that the health care ence (AACN 2007). As of February 2008, 329 indi- system does not make the best use of its resources, and viduals have successfully achieved the CNL credential others (Kimball & OÕNeill 2002, Institute of Medicine and over 1250 students were enrolled in CNL pro- 2003) have urged the health professions to educate grammes across the country (AACN 2008). future practitioners differently. With a heightened From the beginning, evaluation has been an impor- awareness of the need to enhance health care quality tant component of the CNL initiative. The CNL and patient safety, national nurse sensitive indicators Implementation Task Force, the first task force have been identified that are being used to determine the charged in 2004 with overseeing the CNL initiative, quality of care being provided. These include the 2008 worked with education and practice representatives to National Patient Safety Goals (NPSG) established by develop an evaluation plan. At the centre of this plan the Joint Commission (2008a,b) and the 15 National was the CNL Evaluation Scorecard, patterned after the Voluntary Consensus Standards for Nursing Sensitive Kaplan and Norton (1992) Balanced Scorecard. The Care developed by the National Quality Forum. The CNL Evaluation Scorecard includes four domains: Centers for Medicare and Medicaid Services (CMS) quality internal processes, satisfaction, financial out- have implemented pay-for-performance on core measures, which encourages improved quality of care in all 1Second degree or generic masterÕs degree programs are health care settings. CMS is collecting data on 34 those that admit students with baccalaureate and higher quality measures related to five clinical conditions, and degrees in other disciplines and no previous nursing hospital-specific data are being publicly reported on the education. CMS web site. Hospitals scoring in the top 10% for a

ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 16, 614–622 615 J. M. Stanley et al. designated set of quality indicators are paid a bonus (US and understandings (Wolf & Tymiz 1977). The case Department of Health & Human Services, Centers for study is the most appropriate form for reporting the Medicare & Medicaid Services 2005). In addition, CMS results of a naturalistic, summative evaluation such as is moving rapidly to limit payment for services that this (Guba & Lincoln 1981). result from improper care or events that could reason- To highlight the early impact the CNL is having on ably be expected to be averted during hospitalization the health care system, three different partnerships or (Rosenthal 2007). Of the eight conditions for which health care agencies were asked to describe the imple- Medicare will no longer reimburse hospitals, at least mentation of the CNL within that setting, changes that six of the eight are directly impacted by nursing care have occurred, and the impact on patient care. These services. three settings, selected from one geographic region, In response to changes in patient demographics and represent different agencies and patient populations, the health care delivery environment, the American and are at very different stages of the implementation Association of Colleges of Nursing (AACN)2, with continuum. Implementation of the CNL within health multiple practice partners and stakeholders, developed care settings varies depending upon the institution, type a new vision for nursing education and practice. The of setting, and patient population. Each site has expe- clinical nurse leader (CNL), a new clinical nursing role rienced unique outcomes and challenges, which are educated at the masterÕs degree level, is a key compo- highlighted here in three separate case studies. nent of this vision. Individuals prepared to assume this clinical management role, termed an advanced gener- alist, have a unique set of competencies applicable to Findings any health care setting. Practising at the point of care in Case study 1 any microsystem of care (Nelson et al. 2007), the CNL brings a unique perspective to patient care, including an In 2004, the University of Florida (UF) College of emphasis on lateral integration of care, interprofes- Nursing, along with its clinical partner Shands Jack- sional communication, quality improvement, risk sonville, committed itself to implementing the CNL assessment, implementation of evidence-based practice, education-practice model. The education model imple- and patient advocacy. Clinical practice improvement mented was a post-baccalaureate masterÕs degree pro- expert, Marjorie Godfrey of the Dartmouth Institute for gramme. This model was selected to expedite Health Policy and Clinical Practice, recently stated, ÔI graduation of the first cohort of CNLs, which in turn see the CNL as the future leader of quality improvement would facilitate role implementation and evaluation. and patient safety within the microsystem of careÕ Shands Jacksonville, a 733-bed not-for-profit academic (Godfrey Marjorie 2008). health centre located in northeast Florida, was equally committed to seeing the role implemented and evaluated on an acute care unit within its health care system. Methodological approach A new patient-centred care delivery model described Responsive evaluation examines behavioural phenom- by AACN, guided the collaborative efforts of UF and ena using a naturalistic approach. The evaluation of an Shands to design, execute and evaluate the CNL role entity, such as the implementation of the CNL within implementation. Ongoing education-practice liaison the health care system, is organized around concerns meetings included the CNL Track Coordinator at UF and issues of the various stakeholder audiences (e.g. and ShandÕs Director of Education and Practice Coun- patient satisfaction, nurse retention, patient falls, read- cils, along with the identified unitÕs nurse manager, a mission rates, patient education). Using this approach, nurse educator, and a masterÕs-prepared preceptor. the CNLÕs impact on outcomes is compared with an Data base managers and quality improvement person- external set of requirements or with what is considered nel were consulted in the design of the evaluation plan. desirable by the identified stakeholders or in this case, The results of these meetings included a CNL job the national patient safety goals (Guba & Lincoln description, curriculum and preparation of the selected 1981). The outcome of the naturalistic approach is a ÔmodelÕ unit for a full-time 480-hour CNL clinical description of what exists, how people feel, perceptions, immersion experience or residency. A nurse with 5 years experience was encouraged by 2AACN, with over 620 baccalaureate and graduate the Director of WomenÕs and Children Services to apply nursing school members, is the national voice for bac- to the CNL programme, and was subsequently admit- calaureate and graduate nursing education. ted. The student was employed on a maternal-child

616 ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 16, 614–622 The clinical nurse leader unit, but for the immersion experience, was placed on outside agency, which sampled 5–6% of the unit the model unit for the 12-week residency. This studentÕs patients at the end of each month via a phone survey. immersion experience served as the activity around • Length-of-stay data were abstracted to measure the which the role was evaluated. The programme financial domain on the evaluation scorecard. Unit assessment was framed by AACNÕs CNL Evaluation data from summer 2006, the same time period as the Scorecard. studentÕs immersion, were provided for comparison Shands Jacksonville hosts over 30, 000 admissions purposes. per year and has over 4000 employees, 700 of which are nurses. The model unit for the residency was a 17-bed Innovation oncology unit, with 12 RNs, one LPN, and five patient Analysis of the student journal showed that she had care assistants (PCAs). The unit also accommodated focused on refining and improving already existing some medical-surgical overflow patients when needed. initiatives on the unit, including an hourly rounding The CNL studentÕs 3-month residency occurred in initiative. She also streamlined patient access to certified summer 2007. A non-experimental evaluation design chemotherapy nurses and created a protocol and patient was used to track outcome indicators on the model unit. education materials for oral mucositis. Falls were tar- The evaluated data consisted of monthly data from a geted through an initiative that included counselling patient satisfaction survey, length of stay data extracted patients to ask for assistance, placing fall precaution from a monthly report provided to the nurse manager, signs within patient view, and guiding staff to proac- and fall data manually extracted from incident reports tively offer assistance for toileting activities and ambu- and the patient safety and quality department. Retro- lation. spective data, prior to the studentÕs practice on the unit, Journal analysis showed that a majority of the stu- from as far back as a year, also were evaluated. Impact dentÕs time was spent addressing needs of individual was measured as follows. patients (75%), followed by nurses (9%), with the remainder (the unit, family, physicians, patient aggre- • The Innovation domain was measured through con- gates, and other personnel or departments) 4% or less. tent analysis of the studentÕs journals using QSRÕs The most common role functions performed were those XSight qualitative data management tool (Pugh of communication, especially in the advocate role Computers Ltd 2006). Journal entries were broken (29%), followed by risk assessment (15%), care coor- into individual scenarios and examined for common dination (14%), outcome management (12%) and themes. patient education (9%). All CNL role competencies, as • Quality was measured by rates of falls, falls with described by AACN (2007), were achieved by the stu- injury, and the percentage of patients reporting dent during the immersion experience. ÔexcellentÕ in response to a pain management item in a patient survey. Fall rate metrics matched those of the Quality, financial and satisfaction domains AACN evaluation pilot. Table 1 describes outcomes from the quality, financial • Satisfaction was measured by the percentage of and satisfaction domains. The 3-month post-CNL res- patients reporting ÔexcellentÕ in response to an item idency values measure the time period that the CNL asking about the nurseÕs response to calls, as well as student was on the unit for the clinical immersion an item on overall nursing care. These and the pain experience. Data points continued to be provided management satisfaction data were compiled by an through the last quarter of 2007 and through January

Table 1 Outcomes pre- and post-implementation of the CNL on the oncology unit at Shands Jacksonville

May–June 06 Feb.–Apr. 07 May–July 07 Aug.–Oct. 07 Nov.–Jan. 08 Domain/Outcome Indicator Baseline Pre-CNL residency CNL residency Post-CNL residency Post-CNL residency

Quality Pain management 82% 91% 96% 56% 88% Fall rate NA 3.04 7.19 3.09 2.55 Fall with injury rate NA 1.01 2.05 3.09 1.46 Satisfaction Nurses response to calls 58% 71% 96% 89% 72% Overall nursing care 87% 61% 99% 63% 66%

ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 16, 614–622 617 J. M. Stanley et al.

2008, which was after the CNL student had left the unit CNLÕs employment, one of the earliest impacts seen was and returned to her unit of employment. an immediate improvement in communication on the Data in all three domains revealed changes during the remote telemetry unit. The CNL quickly discovered that residency. In addition, after leaving the unit, many of there was little communication between the remote these changes reverted to the values seen prior to the telemetry unit and the units where the telemetry was CNLÕs immersion experience on the unit. Some of the being monitored. She ordered signs with the monitoring changes (e.g. pain management satisfaction, nurses technicianÕs phone number to be posted in each remote response to calls, and overall nursing care satisfaction) telemetry room so the nurses could contact the techni- were favourable, while others, specifically the fall rate, cian immediately if there were questions regarding the were not. Also, the financial domain metric, length of patientÕs rhythm. She also made sure the monitor tech- stay, was difficult to measure and interpret due to the nician had the contact numbers for the nurses on the short time period and variability of types of patients remote unit so he/she could contact the nurse directly if prior to and during the studentÕs immersion experience there was a change in the patientÕs cardiac rhythm. on the unit. On the oncology unit the impact was the guidance Fall and fall with injury rates increased rather than provided by the CNL to the less experienced nurses on decreased during the studentÕs CNL residency experi- the unit. Three nurses who had voiced their intention ence. One reason, supported by the studentÕs journal to leave the unit decided to stay. These three nurses entries, is that in the process of frequent rounding, described the CNL role implementation and the support patients were found to have fallen. Reported fall rates they received as making them feel safer in performing decreased after the CNL student left the unit at the their jobs and therefore willing to stay. Conservative completion of the immersion experience. estimates for the cost of replacing a nurse is $50,000; therefore, retaining these three nurses resulted in an immediate $150,000 saving for the hospital. Case study 2 Unfortunately, the way data on nosocomial pressure In 2004, Morton Plant Mease, a four-hospital 1200-bed ulcer rates, falls with injury, and core measure compli- not-for-profit health system located in Clearwater, FL, ance were collected prior to the CNLÕs being assigned to agreed to partner with the University of South Florida these units makes it impossible to compare similar College of Nursing in implementing the CNL role. outcome data for the beds she was responsible for. Morton Plant MeaseÕs nursing leaders chose to become However, since the implementation of the CNL role on involved in this initiative with the goal that the CNL these two units nearly 2 years ago, the unit reports no would: nosocomial pressure ulcer development, 100% compliance with pneumonia and flu vaccine administration, • improve the quality of patient care through emphasis and the implementation of heart failure patient educa- on implementing evidence-based practice, specifically tion and smoking cessation counselling. The site also CMS core measures; reports that there has been one fall with injury (not • improve communication among the team caring for serious) on the oncology unit and none on the remote the patient; telemetry unit. • provide guidance for less experienced nurses; and An unexpected outcome noted on the oncology unit • assure the patient a smooth flow through the health was the decrease in the average length of stay (LOS) on system. the unit. In 2006 the average LOS was 6.58 days; in The goal was also that these outcomes would be 2007 the average LOS was 5.71; a decrease of accomplished as a budget-neutral project. Since 0.87 days. Because the remote telemetry unit was a employing the first two CNLs in May 2006, these goals newly opened unit when the CNL began, it is not pos- have been met and exceeded. sible to see if there was a similar decrease in the average Two units were initially chosen as pilot units: a 45-bed LOS on that unit as well. oncology unit and a 43-bed medical-surgical unit with In January 2007, a second CNL was added to the 15 telemetry beds remotely monitoring patients. The oncology unit. Although she did not graduate from CNL was responsible for 14 patients on the oncology the CNL education programme until the end of 2007, unit, with a majority of these patients being immuno- the unit benefited from her implementation of the role compromised. The CNL on the medical-surgical unit even as a student. To illustrate the value of the CNL was responsible for providing oversight for the care of role to improving patient care, each of the CNLs on the the patients in the 15 telemetry beds. Following the oncology unit provided a brief narrative of their role.

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ded, get to know them and their needs, integrate Continuity, lateral integration of care and their care, communicate with all involved in the developing a therapeutic relationship care, and provide continuity to the care received.Õ Developing a patient/nurse relationship happens over time. Trust and understanding occurs between both, allowing for difficult decisions to be examined and the Impacting care coordination, patient satisfaction best course of action to be selected. M. Godfrey, a CNL The second CNL assigned to the oncology unit, while working on an adult oncology floor, said in a personal still a CNL student, described some of the ways her role statement in Tucson, AZ in January 2008: had impacted patient care. The two areas she high- ÔAs a CNL I have been fortunate in being able to lighted were care coordination and improved patient develop such relationships and assist my patients to satisfaction. As a CNL student: make choices that will affect their lives. I bring a ÔI have been able to work with other disciplines to different perspective to the patient care setting. I am more effectively transition patients from one able to step back from the day-to-day tasks and healthcare setting to another. For example, work- activities that need to be done and look at the ing with the county health department, I coordi- patientÕs entire treatment plan, needs, risks, nated a hearing from a patientÕs hospital room that expectations and how these intertwine. Because I included physicians, attorneys, and health depart- am there five days a week and work with the ment representatives to have the patient declared a patients not just during the current admission but ward of the state so he could be admitted to the frequently over time, I am able to understand the state tuberculosis hospital for treatment. As a patientÕs needs and choices. I also am able to get result of my intervention as a CNL, the patient to know and work with the family and other received appropriate care and was discharged caregivers. I do a great deal of patient and family safely without putting others at risk. education regarding the diagnosis, treatment plan, expected side effects, and potential complications. Many positive, unsolicited comments have come Because of the long-standing relationship with from patientsÕ families and reflect the care coor- many of the most complex patients, I also am more dination role of the CNL. In one instance, a readily able to identify when changes occur in the patientÕs daughter stated after his transfer to the patientÕs physical or psychological status. The long oncology unit after a two-week hospitalization term relationship also allows for a sense of trust to ‘‘this unit is a bright light in a bleak experience; develop between the CNL and the patient. someone has explained to me what is happening to my father.’’ Another patient commented ‘‘it is Another important aspect of my role is working wonderful here; you have a central person who with the physicians and other health professionals pulls it all together’’Õ. caring for the patient. Because of my relationship with the patient and family, I frequently accom- In 2007 the hospital changed vendors for the physi- pany the physician when discussing the treatment cian satisfaction survey, which makes it impossible to plan and expected outcomes. Having heard the compare before and after data related to the CNLÕs information provided to the patient, I am able to residency. However, physicians have made unsolicited more appropriately address concerns, reactions, comments on the improved communication, better and questions. Lateral integration of care across patient care and improved team work among the nurses settings is another key component of my role. I on the unit. The physicians refer to the CNL as their Ôgo frequently become involved in the timely and to personÕ on the unit. One CNL had a physician say, ÔIf smooth transition from one setting to another I knew you were still here this late, I would not have which significantly impacts the patientÕs satisfac- come in. I would have called you for an assessment tion and quality of care. firstÕ. Another physician commented that the CNLs think critically and have good suggestions about the Although I am a direct care giver, I do not have patientÕs needs when they call. responsibility for implementing daily care to a The nurse manager on the oncology unit commented, group of patients; I oversee the care. This allows ÔThe unit runs so much smoother when the CNLs are me to spend more time with patients when nee- thereÕ. This is supported by similar comments made by

ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 16, 614–622 619 J. M. Stanley et al. case-management personnel. The nurse manager further (RN) and two patient care assistants (PCA). The stated, ÔThe CNLs are able to offer support to the less responsibilities of the CNLs included: lateral integration experienced nurses and the physicians talk to [the of care, interdisciplinary care planning, physician liai- CNLs] first before seeing their patients. They know the son, resource management, system analysis, and pro- patientÕs story because they are here five days a week. I motion of evidence-based practice (see Figure 1). A am so enthusiastic about this roleÕ. sample of the activities engaged in by the CNLs is de- The hospital now has five CNLs on staff covering picted in Figure 2. four different units. There are three additional CNLs on The outcome measures for the CNL project are di- track to graduate in December 2008, with an additional rectly tied to SLMCÕs vision of employee engagement, two in December 2009. All will be placed on hospital customer loyalty and quality care, cost effectively. The units. The long-term goal is to have a minimum of one outcome measures described here are specific to a gen- CNL on each unit. The administration is pleased with eral medical/surgical department (see Table 2). the outcomes produced through the CNL role implementation and finds it a cost-effective method to im- Employee engagement prove patient care. The CNLs on the General Medical/Surgical Department have taken the responsibility of supporting a relatively novice nursing staff. SLMC has been fortunate to re- Case study 3 cruit new, graduate RNs from two local nursing St Lucie Medical Center (SLMC) is a 194-bed for-profit schools. The CNLs focus on mentoring the novice nurse organization located in Port St Lucie, FL. In the summer and building his/her skills in a manner that allows them of 2004, an opportunity arose to partner with Florida to learn in both theory (knowledge) and practice. The Atlantic University (FAU) in the clinical nurse leader learning occurs through various venues; some examples project. The SLMC nursing leadership team viewed this include review of procedures prior to performance, initiative as an opportunity to further improve patient direct supervision of an unfamiliar nursing procedure, care and revise the current nursing care delivery model. and one-on-one education. The CNLs are viewed as Thus a decision was made to move forward with the clinical experts that encourage learning by all staff partnership. After a comprehensive selection and nurses and emphasize the importance of evidence-based interview process, four staff nurses were selected, and in practice. In addition, the CNLs incorporate learning the fall of 2005, began their education to obtain the situations into everyday practice at the point of care and CNL masterÕs degree. sponsor monthly clinical conferences that address Two pilot units were selected to participate in the nursing topics triggered by events on the unit. These CNL project: a 36-bed Progressive Care Department efforts of the CNLs proved to be successful, as reflected and a 45-bed General Medical/Surgical Department. These units were chosen because of a high number of Implements and evaluates patient plan of care throughout hospital new nursing graduates, inconsistent patient satisfaction stay and ensures continuity through the continuum. scores, and a high percentage of patients requiring core Communicates patients’ needs and responses to treatment and collaborates with primary nurses, physicians, and other members measure monitoring. The CNL project was imple- of the health care team. mented in December 2006. Each CNL was assigned 18 Reviews patient information (history and physical, laboratory to 23 patients and worked with three registered nurses tests, radiology exams, progress notes, consults, etc.) and discusses it with physicians during rounds. Leads interdisciplinary rounds every Monday, Wednesday and Lateral integration of care : facilitate, coordinate, and oversee the Friday to communicate, collaborate, and coordinate the care of care provided by the health care team. complicated patients. Interdisciplinary care planning: communicate and collaborate with Educates nursing staff regarding new policies or procedures. other members of the health care team. Ensures core measures compliance by nursing staff and Physician liaison: collaborate with physicians regarding the patient’s physicians. plan of care by taking an active role in patient rounds. Educates patient and family regarding disease processes, tests, Resource person: educate staff through mentoring, coaching and and plan of care. clinical conferences. System analyst: manage and coordinate care at the multidisciplinary Identifies problem areas, and writes or revises unit-based level. procedures and protocols using latest evidence-based practice. Evidence-based practice (EBP): raise questions to challenge Serves as resource person to bedside nurses and assists them with existing practices in an effort to promote EBP. complex patients.

Figure 1 Figure 2 St Lucie Medical Center CNL job description. A day in the life of a CNL at St Lucie Medical Center.

620 ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 16, 614–622 The clinical nurse leader in the low turnover and vacancy rates in the General tion to all disciplines involved in caring for the pa- Medical/Surgical Department (see Table 2). tient. A recent physician satisfaction survey validates the effect of the CNLs in improving staff communi- Customer loyalty cation and the image of nursing (Table 2). • Patient satisfaction and patient-centered care are Quality care, cost effectively areas that the CNLs have identified as priorities on Improvement on the core measure results for SLMC the General Medical/Surgical Department. The CNLs also can be attributed to the efforts made by the focus on improving patient and family awareness and CNLs in staff education and physician collaboration. involvement in the care planning process through On the General Medical/Surgical Department, patients continuous communication. The CNLs visit patients with pneumonia and congestive heart failure (CHF) on a daily basis to review their care plans and diag- and chronic complex patients are the primary focus of noses; patient/family involvement in developing the the CNLs. To ensure compliance with core measure plan of care is encouraged (Figure 2). Some of the indicators, strategies implemented by the CNLs strategies implemented by the CNLs include inten- include colour-coded chart labelling, core measure tional hourly rounding, a unit specific welcome letter alert checklist, concurrent chart review, and continu- for patients and families, bedside care boards, inter- ous staff and physician education on core measure disciplinary rounds, and post-discharge follow-up components. phone calls. On the most recent patient survey results, the General Medical/Surgical Department showed an improvement on questions related to: (a) concern Conclusion shown by staff, (b) family kept informed, (c) nurses While it is tempting to suggest a direct relationship providing explanation, (d) staff communication, and between the implementation of the CNL role and (e) patient treated as a person. SLMC believes that changes in outcome measures, the primary value of these improvements in patient satisfaction scores are examining early outcomes experienced by first adopters direct results of the CNLsÕ efforts in providing a of the CNL role is to raise awareness of the potential for patient and family-centred care approach. improved outcomes of care and cost savings. In addi- • Physician collaboration is an important aspect of the tion, it stresses the need to compare findings of out- CNL role. By taking an active role in physician comes from multiple sites. The intent of the CNL rounding, the CNLs are able to develop strong part- Evaluation Plan is to learn more about what CNLs do nerships, resulting in improved staff communication. and their impact on patient outcomes in diverse health Through this relationship, physicians are afforded a care units and with different patient populations. Early better insight into the role of the CNL. Most evaluation efforts like these provide glimpses into the importantly, acting as a physician liaison, the CNLs potential the CNL role holds for improving patient care have managed to bridge the gap and address the issue outcomes. In addition, the experiences of these three of care fragmentation by providing crucial informa- settings demonstrate significant cost savings in very short periods of time. Similar outcomes are also being

Table 2 reported at other sites across the country. Outcomes of the CNL Implementation at St Lucie Medical Center Before and after CNL implementation outcomes on the General Medical/Surgical Department Implications for nursing management Indicators 4th Q 2006 4th Q 2007 Numerous efforts in the US, including the work of the Employee engagement Institute for Health Initiatives (IHI) and the Robert Nursing turnover rate 11.2% 2.6% Vacancy rate 0.4% Wood Johnson Foundation funded Quality and Safety Customer loyalty Education for Nurses (http://www.qsen.org), have Patient satisfaction 3.25 3.64 focused on quality improvement and patient safety and Physician satisfaction* 2.96 3.13 Quality care cost effectively are achieving positive outcomes. The CNL is not an Core measure – AMI 90% 97% isolated answer. However, through formal, standard- Core measure – CHF 91% 96% ized education programmes, and nationally recognized Core measure – Pneumonia 80% 85% role competencies and expectations, the CNL represents *Annual survey. a promising opportunity for nursing to take a leadership Overall hospital score. role in implementing quality improvement and patient

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622 ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 16, 614–622