Certified Clinical Nurse Leaders Not Hired into the Formal Role: Job Title Survey & Systematic Review
Jacqueline A. Clavo-Hall February 22, 2018
Overview
• My dissertation research • United States health crisis • One nursing solution • Clinical Nurse Leaders Not hired as CNL Clinical Nurse Leaders (NHA CNLs) • Survey report • Systematic Review
2 My dissertation research
• Telehealth for pre-operative anesthesia assessments in rural communities • Touro University California – School of Nursing CNL: Model D • My CNL Journey began
3 Patient Safety and Quality of Care
4 (https://dweaay7e22a7h.cloudfront.net/wp-content_3/uploads/2017/05/shutterstock_166922795-650x360.jpg) Average levels of Quality Received in US
70% receive recommended acute care
60% receive recommended chronic care
50% receive recommended preventive care
30% receive contraindicated acute care
20% receive contraindicated chronic care
5 (Schuster McGlynn & Brook, 2005) CNL History: Patient safety and care quality in danger
• 1999: To Err is Human • 2001: Crossing Quality Chasm
• 2003: Health Professionals Education
• 2010: Future of Nursing
Photos: http://www.amazon.com/s?ie=UTF8&page=1&rh=n%3A283155%2Cp_27%3AInstitute%20of%20Medicine My Dissertation Research
Paper 1 Paper 2 “Certified Clinical Nurse “Roles Enacted by Clinical Leaders Not Hired into the Nurse Leaders Across the Formal Role: Level of Healthcare Spectrum: A engagement and job titles” systematic Literature review”
Journal of Nursing Journal of Professional Administrators Nursing (In preparation) (Published November, 2017)
(Clavo-Hall, J.A., et al., 2017) 7 Nursing’s Proposed Solution to the Problem
AACN Board of Directors and partners created: Task Force on Education and Regulation
• TFER I (2000-2002) Identify how to improve patient safety and care quality
• TFER II (2002-2003) Identify how best to prepare nurses with the competencies needed to thrive in the current and future health care system and focus upon patient safety and care quality
(AACN, 2004; 2012) Proposed Solution: The CNL • AACN accepted TFER II recommendations in 2003
• AACN Launched the CNL initiative in 2004 (education-to-practice partnerships)
• AACN determined that CNL models would be created and evaluated to establish new nursing profession
• Certified CNLs in practice since 2007
(AACN, 2004) Terms & Definitions
1. CNL – A nurse who has graduated from an appropriate CNL program and passed the certification examination (Bender, 2015); CNL faculty who passed examination.
2. CNL Position – A specific position created by health care organizations that place certified CNLs into the workflow on clinical units to enact CNL competency-based activities (Bender, 2015).
3. CNL Role – The enactment of CNL functions and competencies (i.e., skills, knowledge, abilities) across multiple health care settings by a certified CNL.
4. NHA CNL (Not Hired As CNL) – An RN who has met CNL education and certification requirements and is hired in a position other than a formalized CNL position.
10 Literature Review Summary
1. Several studies exploring the CNL role:
o Focused on the CNL role within the CNL position (Stanley et al. (2008); Stanton et al. (2011); Moore & Leahy (2012)
o Combines those hired as CNLs with NHA CNLs.
2. Identifies the impact of CNLs who hold a CNL position, but we know little about the NHA CNLs.
11 Gaps Gaps in literature • A lack of a specific description of the extent to which not hired as (NHA) CNLs engage in CNL competency-based activities
• A lack of NHA CNL perceived barriers to engaging in CNL competency-based activities
Gaps my research will fill • Describe professionals who practice as NHA CNLs
• Describe the level of engagement of NHA CNLs in CNL competency- based activities
• Inform nurse executives of potential uses of NHA CNLs to meet patient and organizational needs
12 Why should we care? • AACN responded to IOM (patient danger reports)
• A new role was created - CNL
• Today 108 schools of nursing offer CNL curriculum
• However, 42% to 60% of all certified CNLs (4271) are not practicing in the role for which they were trained (Bender, 2015; CNC, 2016) . • Preventable errors account for roughly 1/6th of all deaths in the US annually (James, 2013).
• Patients are not likely getting the benefit of the CNL role due to sluggish adoption of the role (Bender, 2015).
• Cost – $25,000 - $60,000 per student (US News, 2018)
Bender, 2012 James, 2013 CNC, 2016 http://cdn.xl.thumbs.canstockphoto.com/canstock18228112.jpg https://www.usnews.com/best-graduate-schools/top-nursing-schools/clinical-nurse-leader-rankings Specific Aims (Paper 1)
1. To describe the extent to which NHA CNLs report engaging in CNL competency-based activities in their current positions.
2. To explore the extent to which NHA CNLs engage in CNL competency-based activities that vary by job titles.
3. To describe the roles certified CNLs are enacting when not hired into formally designated CNL roles.
14 AACN Solution: CNL Workforce
X AACN CNL Skilled Hired into Hired; Not created CNL Workforce CNL Initiative CNL role Hired into role (5350 Total/ 4972 (Partnerships) (2007) Active) CNL Title (CNL role 34% Why should we care?)
(http://www.aacn.nche.edu/leading-initiatives/cnl/cnl-certification/pdf/CNLStats.pdf) To What Extent are NHA CNLs Engaging in CNL Competencies (Broad Areas)? • Clinician • Systems Analyst/Risk Anticipator • Outcomes Manager • Team Manager • Client Advocate • Member of the • Educator Profession
• Information Manager • Lifelong Learner
(AACN, 2007; Bender, 2013; Gilmartin et al., 2015) 16 Inconsistent Terminology
17 (https://www.google.com/imgres?imgurl=http://canacopegdl.com/images/puzzled/p) Method
• Design: Quantitative descriptive survey
• CNC Partnership (Commission on Nurse Certification) ⎯ Infomercial-Announced Survey to all CNLs in CNC Database ⎯ Survey launch on CNC website ⎯ Direct link to information, consent, survey link, ⎯ Starbucks gift certificate ($10); if survey begun ⎯ August 15, 2016 through October 15, 2016
§ Participants: CNC database n =459 After missing data removed: n = 421
• Data Analysis: Statistical Package for the Social Sciences (SPSS)
18 Demographics
(Clavo-Hall, J.A., et al., 2017) 19 Demographics
Age (Years) N % 50 or less 275 65.3 51 or more 104 24.7 Missing 42 10 Total 421 100
Years in Nursing
11 or less 275 61.3 12 or more 125 36.5 Missing 21 2.2 Total 421 100 20 (Clavo-Hall, J.A., et al., 2017)
Results: Job Titles
Staff Nurse
13% Clinical Administrator
Manager
7% 34% Clinical Educator 1%
Clinical Coordinator 3%
Advanced Prac se Nurse 7% Academic Educator - Administrator
2% Clinical Instructor
4% Informa cs 10%
Research - Quality Improvement 5% 14%
Missing
21 (Clavo-Hall, J.A., et al., 2017)
Agency of Employment
Acute care 208 (49.4)
Academic/Education 53 (12.6)
Ambulatory Care 48 (11.4)
Community/Population Health 12 (2.9)
Multiple settings in one health system 12 (2.9)
Other 46 (10.9)
Missing 42 (9.8)
Total 421 (100)
(Clavo-Hall, J.A., et al., 2017) 22 Demographics: Education
Master of Science 341 (80.6)
Education Doctorate 1 (0.2)
Doctor of Nursing Science 1 (0.2)
Doctor of Nursing Practice 15 (3.6)
Doctor of Philosophy 20 (4.8)
Missing 43 (10.2)
Total 421 (100)
(Clavo-Hall, J.A., et al., 2017) 23 Demographics: Employment Location
Urban (50,000 people or more) 332 (78.9)
Rural (less than 50,000 people) 38 (9.0)
Other 5 (1.2)
Not currently practicing as a RN 3 (0.7)
Missing 43 (10.2)
Total 421 (100)
(Clavo-Hall, J.A., et al., 2017) 24 Principal Components Analysis • A dimension-reducing method that explains the theoretical maximum amount of remaining total variance in a correlation matrix.
• A subjects-to-variables ratio to determine the maximum number of variables that should be used with a specified number of observations.
• Goal: To identify a new set of variables (principal components) that explain nearly all of the total variance
(Bryant & Yarnold, 1995) Eigenvectors & Eigenvalues
(https://www.youtube.com/watch?v=BfTMmoDFXyE) CNL Competencies (Broad Areas)?
• Clinician • Systems Analyst/Risk Anticipator • Outcomes Manager • Team Manager • Client Advocate • Member of the • Educator Profession
• Information Manager • Lifelong Learner
(AACN, 2007; Bender, 2013; Gilmartin et al., 2015)
NHA CNL Survey
(Clavo-Hall, J.A., et al., 2017) 28
Subscale of Component Loading for NHA CNL Instrument Items
Component Summary Subscale Component Subscale Mean, Median Item Numbers (Standard Deviation) Component 1: 1,3,6,8,9,10,11 3.08, 3.14 (sd .95) Evidence-Based Practice
Component 2: 2,3,5,7,12 3.21, 3.40 (sd 1.11) Patient Care Management
Component 3: 13, 14, 15 3.77, 4.0 (sd .91) Expert consultant to facilitate interdisciplinary process
29 (Clavo-Hall, J.A., et al., 2017) Job Titles
(Clavo-Hall, J.A., et al., 2017) 30 Job Titles and Principal Components
(Clavo-Hall, J.A., et al., 2017) 23
(Clavo-Hall, J.A., et al., 2017) 31 Limitations
• We do not know how representative our sample is of the entire population of not hired as CNLs.
• No systematic way of identifying the NHA CNL population
• Lacks generalizability
Update
• Patient safety and quality of care - Rates of preventable hospital death rates as high as 400,000/year (Langrigan et al., 2010; James, 2013)
• CNL role specifically create to address safety and care quality; up to 66% not hired as CNLs (CNC, 2016)
• Among 10 top job titles, all engaged in CNL competency-based activities “sometimes to often.” Unable to measure extent; or how varies with job title Recommendations
• Education – Encourage students to identify themselves in workplace as CNLs; document involvement in QI projects.
• Administrators – Identify CNLs in your organization; optimize their education and training to improve safety and quality of care outcomes via an appropriate nursing care delivery model.
• Researchers – Reconsider how CNLs are classified in research studies so that they are analyzed regardless of if they are hired into a formal CNL role
Conclusion of CNL Survey • Prior research has not identified and analyzed CNLs who are not hired into the formal CNL role
• We continue to have this crisis in healthcare, CNLs were one solution to address this problem. We have failed to optimize the use and deployment of this important nursing resource and until such time that we do that it is unlikely that we will address some of the root causes patient safety and care quality problems Paper 2 Roles Enacted by Clinical Nurse Leaders Across the Healthcare Spectrum: A systematic Literature review
Problem: Up to 66% of certified CNLs are not hired into
formally titled CNL roles. (CNC, 2016; Clavo-Hall et all, 2017) Purpose
To report the results of a systematic review of CNL literature to better understand what roles and activities certified CNLs are engaged in when not hired into formally designated CNL roles. Search Strategy
• Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA)
• PUBMED; Cumulative Index to Nursing and Allied Health Literature (CINAHL)
• Key words: “Clinical Nurse Leader” OR CNL • Inclusion criteria • Exclusion criteria
38 Search Criteria
• Inclusion:
o English
o Roles outside formally designated CNL roles
• Exclusion:
o No information on “not hired as” (NHA) CNL roles
39 Search Strategy
(Clavo-Hall, J.A., et al., 2017) 40 Types of Articles Included
Type Percentage
CNL Education or Practice 46% (Baker, 2015; Jukkala, 2013; Stanley, 2008)
Potentials for CNLs in Practice 20% (Edouard-Trevathan, 2010; McGowan, 2016)
Non-CNL Research Reports 25% (Beauvais 2014a; 2014b; Lampe 2014)
(Clavo-Hall, J.A., et al., 2017) 41 41 Data Extraction Categories
• Publication year • Broad role type • First author • Duplicate author • Story-summary • Roles NHAs fulfilled • Theme • NHA CNL Summary • NHA CNL roe • CNL Competencies description • Role type
NHA CNL Excel Workbook
43 (Clavo-Hall, J.A., et al., 2017) 44 NHA CNL: Role Types
o Clinical and non-clinical
o Single article è more than 1 CNL role
Role Percentage Faculty 62% Clinical Management 12% Specialty Clinical 11%
Staff nurse (traditional) 9%
Other 5%
Total 99%
(Clavo-Hall, J.A., et al., 2017) 45 NHA CNL: Role Activities
Activity Percentage
Expert Commentary 33%
Developing/Implementing 22% Academic Curriculum
Developing/Reporting on CNL 18% Implementation in Health Systems Conducting Systematic 10% Literature Reviews
Research 14%
Total 97%
(Clavo-Hall, J.A., et al., 2017) 46 47 Findings Compared
Clavo-Hall et al. Systematic Review Recent Studies Up to 66 % practicing as NHA CNL roles Bender (2016) found 43 % of respondents practicing in NHA CNL roles
-Clinical practice 20% -Clinical practice 18% -Management 12% -Management 43% -Faculty 62% -Education 27% NHAs see themselves enacting AACN Job Analysis competencies through traditional roles -2011 – 16.7% response rate (40% described current role as CNL; 26% described their specific job title as CNL) -CNLs practicing inside the outside AACN microsystem -Ten 1s (AACN 2007) -CNLs enacting leadership roles across - Assumption 1: CNL at healthcare and academic continuum microsystem - Assumption 10: CNL in Leadership 48 (Clavo-Hall, J.A., et al., 2017) CNL Assumptions
1. Practice is at the microsystems level 2. Patient outcomes are the measure of quality practice 3. Practice guidelines are based on evidence 4. Patient-centered practice is intra and interdisciplinary 5. Information will maximize self-care and patient decision making 6. Nursing assessment is the basis for theory and knowledge development 7. Good fiscal stewardship is a condition of quality care 8. Social justice is an essential nursing value 9. Communication technology will facilitate the continuity and comprehensiveness of care 10. The CNL must assume guardianship for the nursing professions
49 Implications for Nursing Education
Assumption 1:Practice is at Literature review findings: the microsystems level. § Majority of job titles outside • CNL to function at of microsystem level microsystem level § Faculty, managers, • Be accountable for a set of executives = 74 % of NHA clinical outcomes CNL respondents • Specific patient population § Majority of respondents not • NOT functioning as practicing at the “point-of- administrators and managers care” (microsystem) § Not always associated with a specific patient population
50 Implications for Nursing Education
Assumption 10: The CNL must Literature review findings: assume guardianship for the ü CNL are filling such positions nursing profession. ü NHA CNLs fulfilling the assumptions in CNL White The ability of professional Paper nursing to fulfill its covenant with ü Faculty determined the need society and protect and promote for CNL certification the health of citizens and communities will depend on the ü Faculty in a CNL programs health care leadership of the biggest contributors to CNL… identified NHA CNL activities (60%).
51 Limitations
• Inconsistent terminology for CNLs not practicing under the title of CNL • Includes only articles published at time of literature search • Does not include CNLs publishing work without using CNL credentials • Scarcity of articles that directly address NHA CNLs • Possible selection bias
52 Conclusion
• CNL role a decade old now • First systematic review of literature on NHA CNL • Solid beginning of describing the literature on NHA CNL • New questions on the impact of
o Inconsistent terminology
o Role NHA CNLs inside and outside clinical microsystem
o Outcome impact of NHA CNLs hired as “regular” RNs
53 Your Turn???
(http://blog.msimsi.com/wp-content/uploads/2012/10/Research_questions2.jpg) 54 Audience Questions
• Do you work with NHA CNLs? • Do you observe NHAs enacting in competencies/broad areas described in the original AACN vision? • Do you believe intent of the AACN leaders’ statements, “the CNL functions within a microsystem’’ has changed over the past decade? • Do we keep the title or do we invest in learning the value of NHA CNLs on patient quality and safety outcomes?
55 References -American Association of Colleges of Nursing (2004). Working statement comparing the clinical nurse leader and clinical nurse specialist roles: Similarities, differences and complementarities. American Association of Colleges of Nursing. -American Association of Colleges of Nursing (2007). White paper on the education and role of the clinical nurse leader. Retrieved from http:// www.aacn.nche.edu/ publications/white-papers/ClinicalNurseLeader.pdf. -American Association of Colleges of Nursing (2013). Competencies and curricular expecta- tions for clinical nurse leader education and practice. American Association of Colleges of Nursing. -Bender, M., Connelly, C. D., Glaser, D., & Brown, C. (2012). Clinical nurse leader impact on microsystem care quality. Nursing Research, 61(5), 326– 332 https://doi.org/10.1097/ NNR.0b013e318265a5b6. -Bender, M., Connelly, C. D., & Brown, C. (2013). Interdisciplinary collaboration: the role of the clinical nurse leader. Journal of Nursing Management, 21(1), 165–174. http://doi.org/10.1111/j.1365-2834.2012.01385.x -Clavo-Hall, J.A., et al., Roles enacted by Clinical Nurse Leaders across the healthcare spectrum: A systematic literature review, Journal of Professional Nursing (2017), https://doi.org/10.1016/j.profnurs.2017.11.007 . -Commission on Nurse Certification (2016). Clinical Nurse Leader CNL 2016 Job Analysis. -Gilmartin, M. J., & Nokes, K. (2015). A Self-Efficacy Scale for Clinical Nurse Leaders: Results of a Pilot Study. Nursing Economic$, 33(3), 133–143. -Institute of Medicine (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press -Institute of Medicine (U.S.)., Greiner, A., & Knebel, E. (2003). Health professions education: A bridge to quality. Washington, D.C: National Academies Press. -Institute of Medicine (2010). The Future of Nursing: Leading Change, Advancing Health. Washington D.C.: The National Academies Press -Institute of Medicine (2000). To Err Is Human: Building a Safer Health System. (L. T. Kohn, Ed.) Washington, D.C: : National Academy Press -James, J. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Retrieved 2015, from PubMed: 10.1097/PTS. 0b013e3182948a69 -Landrigan, C.P., Parry, G.J., Bones, C.B., Hackbarth, A.D., Goldmann, D.A,. Sharek, P.J. (2010). Temporal trends in rates of patient harm resulting from medical care. New England Journal of Medicine , 363, 2124-2134. -Moore, L.W., Leahy, C. (2012). Implementing the New Clinical Nurse Leader Role While Gleaning Insights From the Past. Journal of Professional Nursing , 28 (3), 139-146. -Schuster, M. A., McGlynn, E.A., & Brook, R.H. (1998). How good is the quality of health care in the United States:. The Milbank Quarterly, 76(4), 517-563 -Spiva, L., Hart, P.L., Wesley, M., Gallagher, E., Waggoner, J....Threatt, J.L. (2014). Psychometric Testing of the Clinical Nurse Leader Staff Statisfaction Instrument. Journal of Nursing Measurement , 22 (2), 302-311. -Stanley, J. M., Gannon, H., Gabuat, J., Hartranft, S., Adams, N., Mayes, C., . . . Burch, D. (2008). The clinical nurse leader: A catalyst for improving quality and patient safety. Journal of Nursing Management , 16, 614–622. -Stanton, M.P., Barnett Lammon, C.A.., Williams, E.S. (2011). The Clinical Nurse Leader: A Comparitive Study of the American Association of Colleges of Nursing Vision to Role Implementation. Journal of Professional Nursing , 27 (2), 78-83. http://doi.org/10.1016/j.profnurs.2010.09.014.
(Additional references and information are available upon request: Jacqueline Clavo-Hall, PhD, JD, CRNA, CNL [email protected])