Journal of Nursing Management, 2016, 24, E23–E31

Conceptualizing clinical nurse leader practice: an interpretive synthesis

MIRIAM BENDER PhD, RN Assistant Professor, Program in Nursing Science, University of California, Irvine, CA, USA

Correspondence BENDER M. (2016) Journal of Nursing Management 24, E23–E31. Miriam Bender Conceptualizing clinical nurse leader practice: an interpretive synthesis Program in Nursing Science University of California, Irvine Background The Institute of Medicine’s Future of Nursing report identifies the 252C Berk Hall clinical nurse leader as an innovative new role for meeting higher health-care Irvine quality standards. However, specific clinical nurse leader practices influencing CA 92697-3959 documented quality outcomes remain unclear. Lack of practice clarity limits the USA ability to articulate, implement and measure clinical nurse leader-specific practice E-mail: [email protected] and quality outcomes. Purpose and methods Interpretive synthesis design and grounded theory analysis were used to develop a theoretical understanding of clinical nurse leader practice that can facilitate systematic and replicable implementation across health-care settings. Results The core phenomenon of clinical nurse leader practice is continuous clinical leadership, which involves four fundamental activities: facilitating effective ongoing communication; strengthening intra and interprofessional relationships; building and sustaining teams; and supporting staff engagement. Conclusion Clinical nurse leaders continuously communicate and develop relationships within and across professions to promote and sustain information exchange, engagement, teamwork and effective care processes at the microsystem level. Implication for nursing management Clinical nurse leader-integrated care delivery systems highlight the benefits of nurse-led models of care for transforming health- care quality. Managers can use this study’s findings to frame an implementation strategy that addresses theoretical domains of clinical nurse leader practice to help ensure practice success. Keywords: care quality, clinical nurse leader, interpretive synthesis, nursing care model

Accepted for publication: 4 December 2014

clinicians from fully translating their abilities, knowl- Background edge and motivation into optimal care performance The American health-care system as currently struc- (Bartels 2005). Consequences include errors in clinical tured, with its disciplinary ‘silo’ approaches to patient practice and preventable adverse patient outcomes care, is characterised by fragmented care delivery sys- such as increased mortality, morbidity, readmission tems lacking formal interprofessional collaborative rates, lengths of stay and care costs (Fewster-Thuente processes (Porter-O’Grady et al. 2010, Baernholdt & & Velsor-Friedrich 2008). Professional, policy and Cottingham 2011). This lack of collaboration has educational organisations have recognised the need to resulted in hierarchical care patterns that prevent transform the health care workplace to better provide

DOI: 10.1111/jonm.12285 ª 2015 John Wiley & Sons Ltd E23 M. Bender patient centred and team oriented care (Interprofes- in action. A literature search was performed in the sional Education Collaborative 2011). Cumulative Index to Nursing & Allied Health Litera- As part of this transformation, The American Asso- ture (CINAHL), PsycINFO, Pubmed and Dissertations ciation of Colleges of Nursing (AACN) spearheaded & Theses using the term ‘clinical nurse leader’. The the development of the clinical nurse leader (CNL), a time frame was 2000–2012, to capture potentially Master’s-prepared registered nurse (RN) educated to meaningful reports describing early CNL role develop- coordinate patient care through collaboration with the ment initiatives as well as later implementation and health-care team at the microsystem level (AACN outcome reports. A grey search was also performed in 2007). Microsystems are the cultural units in which Google that identified the Virginia Henderson Interna- multiple clinicians are situated to provide care to tional Nursing Library, Agency for Healthcare patients, and where the quality and safety of care is Research and Quality (AHRQ) Innovations Exchange ultimately determined, which makes it an important and AACN websites as additional sources of CNL focus for action (Nelson et al. 2008). Numerous narratives. The search returned 400 unique docu- reports have documented the development, implemen- ments. This study did not exclude reports from the tation and outcomes of these CNL partnerships (for a synthesis on the grounds of poor methodology, which review see Bender 2014). is consistent with previous interpretive synthesis stud- However, CNL practice is not yet understood in ies (Dixon-Woods et al. 2006, Thorpe et al. 2009). terms of the essential practices necessary to influence The focus instead was on identifying descriptions of documented quality outcomes (Fitzpatrick & Wallace CNL practices embedded within the documents; 2008). Notably, variation in CNL implementation has reports were included if they described some aspect of been found across reports, leading to questions about CNL practice in action (see Figure 1 for flowchart). which CNL practices mediate commonly reported out- Thirty CNL practice reports, eight qualitative or comes (Bender 2014). The ambiguity surrounding mixed methods studies, three quantitative correlation CNL practice reflects the overall absence in the litera- studies and 254 conference abstracts were included in ture of a well-defined theoretical framework to help the synthesis. Document characteristics including first guide CNL application in practice. Recognising the author, year, category and stated aims are detailed in importance of defining CNL practice as a basis for Table S1, which includes a bibliography of all informing and evaluating future CNL implementations included reports. Abstract characteristics, including and expected practice outcomes, the purpose of this category, title, year and source are detailed in Table study was to gain a theoretical understanding of fun- S2. damental CNL practices and their connection with care outcomes.

Reports idenƟfied through: CINAHL, Pubmed, Dissertations & Theses, Grey Search Methods (Search term: “clinical nurse leader”) An interpretive synthesis design was used to integrate Total reports retrieved methodologically diverse CNL practice narratives into (n = 473) a conceptual understanding of CNL practice. Interpre- Duplicates removed (n = 73) tive synthesis involves the integration of primary evi- Reports screened by Ɵtle (n = 400) dence related to a phenomenon of interest through Reports excluded: Not about CNL reinterpretation and reanalysis of pre-existing textual (n = 16) Reports reviewed for inclusion evidence. Its strength is it can be conducted on diverse (n = 384) forms of primary evidence (Dixon-Woods et al. 2004, Reports excluded: Editorial/Journalism Mays et al. 2005). Interpretive synthesis generates Reports included in synthesis: (n = 89) new interpretations of a phenomenon of interest not Documented CNL pracƟce found in any single report, but derived from synthesis- (n = 295) ing all reports as a whole (Thorne et al. 2004).

CNL pracƟce QualitaƟve QuanƟtaƟve CNL conference reports studies studies abstracts Literature search (n = 30) (n = 8) (n = 3) (n = 254)

Purposeful sampling of the literature was used to iden- Figure 1 tify documents describing clinical nurse leader practice Literature search flow chart.

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CNLs were constantly obtaining information from all Analysis and synthesis microsystem clinicians, managers and staff via their The complete texts for all included documents were microsystem presence on a continuous basis, and were analysed following Strauss and Corbin’s grounded the- available to communicate this information on an as- ory methods (Strauss & Corbin 2007). This qualita- needed basis to any that need it. The CNLs developed tive, comparative approach is well suited to multi-modal communication tools to effectively trans- reinterpretation and reanalysis of text-based forms of mit gathered information across the microsystem, evidence (Pope et al. 2007). Data handling and analy- including cross-disciplinary electronic databases, care sis was facilitated through use of Dedoose, a web- guidelines and holistic care plans. The CNLs were also based qualitative and mixed methods analytical appli- accountable for developing and sustaining many types cation package (Lieber & Weisner 2010). Excerpting, of formal and informal rounding structures such as coding and memoing were conducted within the appli- staff nurse daily huddles, targeted patient assessment cation package. Line-by-line coding of the texts during rounds (e.g. daily skin or invasive line assessments grounded theory analysis resulted in 1311 excerpts with staff and/or physicians) and formal multi-profes- abstracted into 58 preliminary codes. As relationships sional staff rounds. Staff nurses, charge nurses, became apparent, primary codes were refined and physicians, CNLs and other clinicians regularly integrated into groups representing diverse compo- used these communication tools and rounding struc- nents of CNL practice. As patterns of connectivity tures to convey care needs to other clinicians and to emerged, groups of components were refined and syn- each other during and across shifts and the care thesised into domains of CNL practice. Domain codes spectrum. were densely distributed across the literature, provid- ing evidence of data saturation. Strengthening interprofessional relationships A significant portion of CNL workflow is time spent Results engaging with all members of the clinical microsystem. The core phenomenon of CNL practice is continuous Building relationships is time consuming and can be clinical leadership, which involves four fundamental difficult at first. While multidisciplinary clinicians domains or activities: facilitating effective ongoing might recognise the need to reach out to all members communication; strengthening intra and interprofes- of the care team when planning and implementing sional relationships; building and sustaining teams; patient care, the structures of their own practice often and supporting staff engagement (see Table 1). The make this impossible on a regular basis: busy clini- following sections describe domains of CNL practice cians currently work in professional silos that priori- in greater depth. tise superb clinical skills and a narrowed focus of care while discounting seemingly non-clinical skills such as relationship building. Clinical nurse leader practice Facilitating effective ongoing communication corrects this flaw by creating formal microsystem Clinical nurse leaders start the communication process accountability to reach out and make meaningful con- by embedding themselves within their microsystem to nections with patients and all multi-professional clini- learn and understand practice dynamics. As one CNL cians involved in patient care. This formal and put it: ‘It is necessary for the unit based and/or setting continuous relationship builds bridges and sustains in- based CNL to become absorbed in the unit/setting cul- terprofessional connectivity, which is generally missing ture ... working side by side with staff’ (Swan 2011, in most clinical microsystems but is a critical anteced- p. 28). Clinical nurse leaders were described as ‘con- ent for interprofessional collaboration and shared sistent points of communication’ for the entire care decision-making (San Martin-Rodriguez et al. 2005). team. One CNL put it this way’ ‘I think the biggest One report’s description typifies this correction of thing I work on everyday is communication ... Trying ‘silo’ practice after CNL implementation: ‘within just to keep people all together on the same page is the a few years, the CNLs have established a network of biggest thing I do’ (Sorbello 2010, p. 72). partners who once may have acted in isolation. They Clinical nurse leaders talked about building ‘knowl- have increased collaboration among disciplines in both edge banks’ through ongoing communication with clinical and non-clinical settings’ (Wilson et al. 2013, everyone entering the microsystem over time. The p. 177).

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Table 1 Domains of the core phenomenon of CNL practice: continuous clinical leadership

Domain What it means What it looks like Influence on microsystem

Facilitate effective Use multiple domains of communication: Synthesise various pieces of Communication is advocacy: for ongoing communication written, spoken, nonverbal information into coherent story patient, for staff, for better care processes Cross professional databases, Bridges staff and interprofessional care plans, electronic health records team’s knowledge gaps Formal rounding, informal huddles, By showing value of different interdepartmental rounds, perspectives, communication interprofessional rounds promotes involvement Knowledge broker Build a resource and knowledge Ensures all voices are heard ‘bank’ through constant during decision-making process informal communication with everyone who touches the patient Crossing professions to get necessary information Strengthen intra and Establish a network of partners Seek out the right people and Creates a sense of ‘we’re in it interprofessional whom previously worked in isolation say ‘I need you’ together’ relationships Share strengths from all areas Relationship broker Daily presence facilitates effective Collaboration is integral to care quality utilisation of previously untapped human resources Connect people that otherwise would Creates insight into how other not have time to seek each other out professions do their work Builds confidence in other professions Relationships create voluntary commitment for action Build and sustain Bring people together with a CNL microsystem perspective helps Teamwork emphasises the teams common goal identify professions/departments importance and interdependency needed on team of all members Empower groups instead of individuals Problems usually cross boundaries Creating a shared vision for change and professions Network facilitates and sustains innovation Put focus on patient-centred care, Transparency of goals and methods Shared vision helps reduce (away from discipline-centred to reach them resistance to change care practices) Engage all professions to bring resources to the table Support staff Facilitate development of Daily mentor/role model for those Build environment where staff engagement staff leadership skills not comfortable or familiar with KNOW they have support to act leadership processes Facilitate action when staff Frontline ideas transformed into recognise problem sustainable quality processes CNL is de-facto early adopter Real-time feedback of new Support builds confidence in processes proposed processes Facilitate continuous, hands-on Continuous, non-threatening Help staff avoid getting lost in educational environment clinical process monitoring the system and feeling overwhelmed Continuous reinforcement of CNL focus on staff’s dynamic practice education provided by CNSs knowledge creates a continuous and nurse educators empowerment feedback cycle at the bedside

coordination resources. Teams included representation Building and sustaining teams from information technology, executive leadership, As intra and interprofessional relationships are built, physicians, nutritional services, respiratory therapy, teams can be formed that have a shared purpose to social work, physical therapy, frontline staff, educa- pursue quality improvement. Team creation was iden- tors, wound ostomy nurses, clinical nurse specialists tified more than any other single component of CNL and the quality department, to name just a few. practice during analysis, with more than 101 excerpts Clinical nurse leaders, through their continuous micro- linked across all reports. The CNL brings people system presence, observe and understand the interde- together with a common goal who nevertheless may pendency of all professions providing care to the have never worked together before because of a lack patient. By bringing together all professions that affect of interprofessional engagement and a dearth of and are affected by microsystem practices, the CNL

ª 2015 John Wiley & Sons Ltd E26 Journal of Nursing Management, 2016, 24, E23–E31 Conceptualizing clinical nurse leader practice emphasises the importance of all professions in care facilitates shared decision making – it also is good role functions. Team building creates interdependency that modelling for [medical] trainees so they incorporate helps align motivation for solving common care pro- regular discussions with RN into their workflow’ cess problems, including many that were described as (Bender et al. 2013, p. 171). Another report ‘entrenched’ before CNL implementation. explained: ‘[CNLs are] the communication hub between physicians, care team leaders, staff nurses, social workers, members of other disciplines, and the Supporting staff engagement patients/family members to ensure a comprehensive The CNL does not oversee or manage clinical staff, plan is in place for hospital care and discharge and but provides daily support for them to lead their own that the patient/family is involved in planning care’ practice. The CNL, as a Master’s prepared nurse (Bowcutt et al. 2006, p. 158). working at the patient–health care interface, acts as a Aligning with the initial focus of the CNL to daily mentor and role model to new staff and all inter- improve care outcomes, standardised health-care qual- professional clinicians within a microsystem. Clinical ity metrics were reported as CNL evaluation measures nurse leaders promote and sustain best practices across all reports. Metrics focused on nursing-sensitive through role modelling and are able to reinforce edu- quality indicators such as fall rates, pressure ulcer cation in an informal, non-threatening manner rates, restraint use, nursing turnover, nursing hours through their continuous presence. The CNL is in per patient day and nursing certification rates. effect a continuous resource to staff based on their National quality benchmarking outcomes included needs at the moment. The CNL promotes nurse Joint Commission core measures along with staff and engagement in identifying and creating solutions for patient satisfaction scores. Positive changes in these quality care deficits that are effective, efficient and metrics were consistently reported after CNL imple- nurse-driven: ‘The CNL encourages the nurses on the mentation. Reports stressed this increase in care qual- team to identify patient care, process or work environ- ity was not because of more staff or resources ‘thrown ment issues, and then mentors them through the prob- at the problem’, but through the systematic implemen- lem-solving process’ (Hartranft et al. 2007, p. 262). tation of CNL practice including thoughtful redesign Another report stated: ‘because the bedside nurses of care delivery to integrate CNL practice. As one have the CNLs as a resource, they have begun to view report describes it: ‘Changes were attributed to the their practices differently and challenge the status quo’ CNL’s facilitation of problem solving, decision-mak- (Wilson et al. 2013, p. 180). Another report described ing and improvement of patient flow. It is important a similar process of staff engagement resulting from to note a basic premise of the pilot was that the CNL the role modelling and support of the CNL: ‘Staff per- was not intended to represent an increase in person- formance improved as staff began to work on profes- nel. Our interpretation of these findings is that incor- sional goals.... Nursing staff also became the model porating a CNL into the nurse staffing pattern for the facility for implementing new processes’ (Fitz- resulted in more efficient, outcomes-driven hours in patrick & Wallace 2008, p. 182). direct care.’ (Ott et al. 2009, p. 366).

Outcomes of clinical nurse leader practice Discussion By consistently gathering and communicating informa- The purpose of this study was to develop a theoretical tion across professions, building intra and interprofes- understanding of clinical nurse leader practice that sional relationships, facilitating effective teamwork, can facilitate systematic and replicable implementation and harnessing frontline staff knowledge of care defi- across health-care settings. Theory makes explicit how cits and their ideas for improvement, CNLs put the a complex intervention, such as clinical nurse leader pieces in place to change the microsystem focus away practice, influences a process or processes in a causal from individual tasks and towards a broader under- chain from intervention to outcome (Craig et al. standing of how everyone plays a part in complex care 2008). Theory provides the tools to recognise, analyse processes to provide quality patient care. Better inter- and act on intervention implementation issues in a professional relations and information sharing leads to more effective manner (Sales et al. 2006). It is impor- better decision making for patient care, as described tant to develop theory that explains the ‘what’ of by a physician: ‘[CNL practice] is a major improve- CNL practice and the functional relationship between ment in MD [physician]–RN communication and CNL practice and improved care quality so health

ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, E23–E31 E27 M. Bender systems can use this information as a framework for tion factors that influence engagement include effective systematic and effective CNL practice implementation leadership and the ways nursing care delivery is organ- and to consistently achieve expected outcomes. ised (Spence Laschinger & Leiter 2006). Clinical nurse leader practice can be considered an effective approach to integrating clinical leadership into a nurs- Clinical nurse leader practice promotes evidence ing model of care that consistently prioritises relation- based elements of care delivery ship building and engagement for ALL professionals This study has identified continuous clinical leadership working within a clinical microsystem. as the core phenomenon of CNL practice, which includes facilitating ongoing effective communication CNL-integrated microsystems effectively leverage and teamwork. Communication and teamwork have clinical leadership been identified as critical elements of quality health- care delivery (Shekelle et al. 2013). Within a microsys- There is a small but growing body of conceptual and tem, nurses, physicians, case managers, physical thera- empirical literature defining and supporting the need pists and many other clinicians work side by side to for clinical leadership to improve health-care quality. deliver patient care. These clinicians comprise the mi- Clinical leadership is conceptualised in the literature crosystem ‘team’, yet traditional microsystem care as an ongoing process that involves communication, delivery structures remain discipline focused, with no collaboration and team building by ‘competent clini- accountability or resources devoted to ensuring that cians’ to engage health-care providers in health-care clinicians communicate and work together as a team improvement (Millward & Bryan 2005, Howieson & to deliver patient care. One strategy for increasing the Thiagarajah 2011, Willcocks 2011, Mannix et al. potential for communication and teamwork is modify- 2013). Clinical nurse leader practice has been identi- ing health-care tasks, workflow and structures so they fied as continuous clinical leadership in this study: a are more amenable to cross-disciplinary communica- continuously enacted bundle of four clinical leadership tion and teamwork (Baker et al. 2006). Integrating activities (facilitating effective ongoing communica- CNL practice into a thoughtfully redesigned care deliv- tion, strengthening intra and interprofessional rela- ery microsystem is one approach for modifying the tionships, building and sustaining teams and structures and processes of care delivery to promote supporting staff engagement) that improve health care consistent and effective communication and teamwork. quality over time. This synthesis also identified building intra and in- The literature is less clear in identifying the ‘compe- terprofessional relationships and promoting staff tent clinicians’ best positioned to be clinical leaders, engagement as fundamental CNL clinical leadership or how clinical leadership should be structured for activities. Relationship building is a critical antecedent best outcomes (Daly et al. 2014). A recent study to effective collaboration and engagement: profession- acknowledged that expectations and training for clini- als must know each other before they can make mean- cal leadership in front-line staff were not enough to ingful decisions to trust and collaborate with each sustain clinical leadership behaviours; it needed to be other (D’Amour et al. 2008). Unfortunately, current ‘complemented’ by elements of traditional leadership health-care structures and processes largely consist of and management, and supported by executive leaders short-lived, irregular configurations of professionals to be successful (McKee et al. 2013). Other reports working together to solve short-term clinical prob- have also identified the need for a supporting infra- lems, rather than a stable cohort of clinicians working structure and alignment with organisational strategy together in a collaborative manner (Lewin & Reeves to support clinical leadership (Fealy et al. 2011, Leg- 2011). The same is true for staff engagement, which gat 2013, Martin & Waring 2013), which suggests has been linked to positive patient safety outcomes that clinical leadership can only be as successful as the (Spence Laschinger & Leiter 2006). Engagement is infrastructure that supports it. influenced by the level of opportunities for interper- This understanding of the need for a supportive sonal relationships, which is shaped more by organisa- infrastructure for successful clinical leadership aligns tion factors than individual factors (Simpson 2009). with the findings of this study and helps explain why Contexts that are not amenable to relationship build- CNL practice is effective in improving health-care ing, such as the current health-care structures quality. Clinical nurse leader practice can be described above, reduce the opportunities for considered an effective strategy for organising clinical interpersonal relationships and engagement. Organisa- leadership in a way that places accountability for

ª 2015 John Wiley & Sons Ltd E28 Journal of Nursing Management, 2016, 24, E23–E31 Conceptualizing clinical nurse leader practice clinical leadership activities in a Master’s prepared CNL practice as part of care delivery redesign to nursing role that is embedded into care delivery struc- improve care quality. To ensure CNL practice success, tures with organisation supports and resources. The it is important to recognise that variability in CNL CNLs are in effect preliminary (though certainly not practice has been associated with role confusion and the only) ‘competent clinicians’ who through a struc- inconsistency in outcomes (Bender 2014). This study tured role with specific accountabilities provide an provides a preliminary theoretical framework for CNL ongoing resource for clinicians to strengthen their practice that defines fundamental CNL activities and own clinical leadership development and practice. The describes the relationship between the ways this bun- CNL in turn is supported by organisation resource dle of activities is organised and improvements in mi- allocation (a title, a salary, a consistent workflow, crosystem care quality. Managers must recognise the etc.) to sustain clinical leadership activities. The result need to fully integrate CNL practice into redesigned is a microsystem with multiple supports to promote care delivery models and to develop CNL workflows clinical leadership practice for all clinicians. Clinical that consistently incorporate all fundamental CNL nurse leader practice, integrated into nursing care activities to reduce the risk of role confusion and to delivery microsystems, can be considered an alternate ensure that CNL practice will result in expected care approach for achieving the goal of clinical leadership quality improvements. If expected outcomes are not behaviours to improve health-care quality for all being realised, managers can use this study’s findings frontline staff, moving beyond traditional episodic to determine if CNL practice is adequately integrated education and training approaches. into the microsystem’s nursing care delivery model, or whether CNL workflow may have drifted away from theory-based practice. Is CNL practice consistent, or Limitations and future research are CNLs also engaging in non-CNL roles, such as This study synthesised all available CNL evidence charge nurse or staff nurse, or administrator? Are reported in the literature to-date to develop a concep- CNLs consistently available to clinicians as a role tual understanding of CNL practice. It is recognised model and resource for practice? Are CNLs develop- that synthesis is an interpretive endeavour and other ing multi-modal information tools that all clinicians interpretations of the data are possible. Furthermore, can use to base practice decisions? Inadequately sup- the synthesis could not include what was not pub- ported CNL practice and/or CNL workflow that has lished: unpublished CNL case studies and narratives drifted from theoretically defined practice can explain may have unique trajectories and outcomes that could the lack of expected results, and managers can work not be included to produce a more comprehensive to refine CNL supports and workflow to ensure it conceptualisation of CNL practice. Prospective consistently adheres to theory-based practice to research is warranted to validate domains of CNL improve care quality outcomes. practice across a more comprehensive sample of clini- cal microsystems. A validated model for CNL practice Conclusion will provide a solid framework to identify and/or develop measures of CNL practice and quantify CNL- The Future of Nursing report highlights the need to specific influence on care environments and quality. transform nursing models of care to better utilise scarce nursing resources and expertise (IOM 2011). CNL practice has been identified as an innovative Implications for nursing management strategy to meet this challenge (Joynt & Kimball Managers should consider the ways that CNL practice 2008, AHRQ 2010, IOM 2011). This study has con- demonstrates the benefits of nurse-led models of care tributed theoretical knowledge about CNL practice for promoting intra and interprofessional communica- and its influence on care outcomes that provides a pre- tion, collaboration and practice to improve health care liminary framework to facilitate systematic and repli- quality. The interprofessional component of CNL cable implementation across health-care settings. practice identified in this study is important because it expands the boundary of nursing practice to influence Acknowledgements all professions that are making contributions to patient care within a clinical microsystem. Managers The author would like to acknowledge Professors are in a key position to use this study’s findings to Cynthia D. Connelly and Ann M. Mayo at the Univer- frame an implementation strategy that incorporates sity of San Diego Hahn School of Nursing and Health

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