The Current Evidence Base for the Clinical Nurse Leader

15 Pages·2014·0.36 MB·English

UC Irvine
UC Irvine Previously Published Works
Title
The current evidence base for the clinical nurse leader: a narrative review of the
literature.
Permalink
https://escholarship.org/uc/item/4zk140n7
Journal
Journal of professional nursing : official journal of the American Association of Colleges of
Nursing, 30(2)
ISSN
8755-7223
Author
Bender, Miriam
Publication Date
2014-03-01
DOI
10.1016/j.profnurs.2013.08.006

Peer reviewed
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T C E B
HE URRENT VIDENCE ASE FOR THE
C N L : A
LINICAL URSE EADER
N R
ARRATIVE EVIEW OF THE
L
ITERATURE
⁎
MIRIAM BENDER, PHD, RN, CNL
Theclinicalnurseleader(CNL)isarelativelynewnursingrole,introducedin2003throughthe
American Association of Colleges of Nursing (AACN). A narrative review of the extant CNL
literature was conducted with the aim of comprehensively summarizing the broad and
methodologicallydiverseCNLevidencebase.Thereviewincluded25implementationreports,1
CNL job analysis, 7 qualitative and/or survey studies, and 3 quantitative studies. All CNL
implementation reports and studies described improved care quality outcomes after
introduction of the role into a care delivery microsystem. Despite preliminary evidence
supporting the CNL as an innovative new nursing role capable of consistently improving care
qualitywhereveritisimplemented,CNLsarestillstrugglingtodefinetheroletothemselvesand
tothehealthcarespectrumatlarge.AlthoughtheAACNCNLWhitePaperprovidesaconcise
model for CNL educational curriculum and end competencies, there is a compelling need for
further research to substantively delineate the CNL role in practice, define care delivery
structures and processes that influence CNL integration, and develop indicators capable of
capturing CNL-specific contributions to improved care quality. (Index words: Clinical nurse
leader; CNL; Review) J Prof Nurs 30:110–123, 2014. © 2014 Elsevier Inc. All rights reserved.
T
HE CLINICAL NURSE leader (CNL) is a relatively a comprehensive narrative review of reports describing
new nursing role, developed to enhance the CNL implementations and research on the role found
efficiencywithwhichcareisdeliveredandtocoordinate in the literature to date, as well as suggestions for
and laterally integrate care through collaboration at the future study.
microsystemwiththeentirehealthcareteam(American
Methodology
AssociationofCollegesofNursing[AACN],2007).Since
its introduction in 2003, more than 200 reports have Anarrativeapproachwasusedtosummarizethecurrent
been published describing CNL theory, conceptual evidence regarding the CNL. Narrative review is consid-
framework, education, and implementation. The role ered a valid strategy for organizing a comprehensive
hasbeenimplementedinmanyhealthcareorganizations, knowledge base that is broad and methodologically
withnumerousreportsofenhancedcollaborativepractice diverse (Collins & Fauser, 2005), such as the current
and improved patient outcomes. This article presents CNL evidence base. A search of CINAHL, PsychINFO,
Pubmed, and Dissertations & Theses was undertaken
usingthephraseclinicalnurseleader,fromJanuary1995
∗Lecturer,UniversityofSanDiegoHahnSchoolofNursingandHealth toNovember 2011,with arepeat search inJune 2012to
Science,SanDiego,CA.
capture any newly released publications. The grey
Outcomes Research Specialist, Outcomes Research Institute, Sharp
literature was also searched, including Google, Google
Healthcare,SanDiego,CA.
SourceofFundingandConflictofInterest:Theauthorhasnoconflicts Scholar, AACN Web site, AHRQ Innovations Exchange
ofinteresttoreportandnocompetingfinancialinterestsexist. Website,andareviewofallreferenceslistedinextracted
Address correspondence to Dr. Bender: Outcomes Research publications.Thesearchreturned204uniquerecords.All
Specialist, Outcomes Research Institute, Sharp Healthcare, 8695
implementation and research reports on the CNL were
SpectrumCenterBlvd,SanDiego,CA,92123.E-mail:miriam.bender@
included in the narrative review. No reports were
sharp.com
8755-7223/13/$-seefrontmatter excluded on the basis of poor methodology, in the
110 JournalofProfessionalNursing,Vol30,No.2(March/April),2014:pp110–123
http://dx.doi.org/10.1016/j.profnurs.2013.08.006 ©2014ElsevierInc.Allrightsreserved.
CURRENTEVIDENCEBASEFORTHECLINICALNURSELEADER 111
interest of comprehensiveness. Explanatory, theoretical, and patient satisfaction; efficiencies in patient care
or historical articles on the CNL; abstracts; journalism; processes and lengths of stay; improved nursing quality
brief editorials; and articles addressing the CNL tangen- indicators such as falls, discharge teaching, sitter hours,
tially were excluded from the review. The final sample and hospital acquired pressure ulcers; increased staff
included25implementationreports,1CNLjobanalysis, registerednurse(RN)certificationrates;improvedhome
7qualitativeorsurveystudies,and3quantitativestudies health referral rates; decreased staff turnover; improved
(see Figure 1). patient outcomes targeting infection rates, ventilator-
associated pneumonia, transfusion rates, and restorative
Results dining; and improved interdisciplinary communication
and collaboration (see Table 1).
CNL Pilot Implementations
CNL Job Analysis
AftertheinitialCNLWhitePaperwaspublishedin2003,
The AACN established a CNL Implementation Task The Commission on Nursing Certification (CNC)
Force (ITF) in 2004, charged with developing the authorized a job analysis in 2011 to establish the link
curriculum and end-of-program competencies for CNL between CNL certification examination test scores and
education, as well as a standardized evaluation frame- the competencies being tested (CNC, 2011). Job de-
workforCNLpilotimplementations(Bartels&Bednash, scriptions, journal articles, reference books, Web sites,
2005;Harris,Tornabeni,&Walters,2006).Seventy-nine and other relevant search materials were reviewed to
schoolsofnursingand143practicesiteswereinvolvedin createadraftlistofessentialCNLskillsandactivities.An
the first phase of the pilot CNL education and practice expert panel then worked to clarify performance
implementations (Tornabeni, 2006). The ITF developed activities, knowledge skills, and abilities required of a
numerous education/practice partnerships across the competentcertifiedCNL.Theresultsformedthebasisof
country to educate and train the first CNLs who a survey instrument sent (via e-mail) to 1,560 certified
pioneered the role in their respective practice settings. CNLs across the country to validate skills and activities.
The results of many of these pilot implementations, as The adjusted response rate was 16.7%. The survey
well as independent CNL intervention trials, have been content was determined to be adequate: 98% respon-
described in the literature. These reports describe the dents indicated that the survey either adequately or
work completed through partnership between academia completely covered the important tasks performed by a
andpracticesettingstooperationalizetheeducationand competentCNL.ReliabilitywascalculatedasCronbach's
clinical training of the first CNLs, and describe how alpha .99 for importance ratings. Although all respon-
organizations operationalized the role within their dents were certified CNLs, only 26% were currently
practice settings (for details please, see Table 1). The working in a formally titled CNL role. Other job titles
articles report a host of quality improvements demon- included nurse educator (16%), staff RN (10%), and
strated after CNL integration into various care delivery manager/director (13%). The rest were spread across a
systems. These include the following: increased nursing wideswathofjobtitles.Fifty-ninepercentworkedinthe
time spent with the patient; improved staff, physician, acute care setting, 14% worked in schools of nursing,
Figure1. Literaturesearchflowdiagram.
112 MIRIAMBENDER
and the rest were evenly spread across a variety of differenceevokespride,(c)bringingthebedsidepointof
outpatient environments. view,(d)knowingthepatientascaringperson,(e)living
Tasks were bundled into 17 subdomains for CNL caring with nurses, and (f) needing to be known,
practice.Respondentswereaskedtoallocatepercentages understood, and affirmed. CNLs saw the “big picture,”
tothesubdomains,reflectingthepercentageofquestions and therefore could connect the dots in terms of
that should be assigned to each subdomain based on coordinating what patients needed from numerous
perceived importance to practice. The results are shown disciplines and making sure “nothing fell through the
in Table 2. The three most important subdomains for cracks.” This required prodigious amounts of tenacity
CNL practice, as judged by certified CNLS, were (a) and perseverance, but was a great source of job
evidence-based practice, (b) interdisciplinary communi- satisfaction and pride for each CNL. It was also the
cation and collaborative skills, and (c) quality improve- source of the respect other practitioners developed for
ment. The three least important perceived subdomains each CNL as their skills and commitment became
forCNLpracticewere(17)healthcarepolicy,(16)health apparent. The CNLs had the time to get to know the
care finance and economics, and (15) health care patientandfamiliesthroughouttheirstay,whichenabled
informatics. them to translate what was happening throughout their
admission in ways that were meaningful to the patients
CNL Research
and their families. This was doubly true for the nursing
The CNL initiative is still in its infancy, and systematic staff:BecauseoftheCNL'sdailypresence,theywereable
researchontheCNLroleislimited,butsevenqualitative to forge relationships with the staff and mentor them
and survey studies were identified that help to better through role modeling, actively assisting with complex
understandthe CNL in practice(see Table 3),and three patient care needs, and recognizing staff for their
quantitative studies (two with control groups) have achievements. Finally, although the CNLs worked hard
produced preliminary evidence correlating CNL imple- toensurethatthemultidisciplinaryteamappreciatedthe
mentation with improved outcomes (see Table4). achievements of the staff nurses, it was hard to find the
same recognition for their own work. They were
Qualitative CNL Research
repeatedly pulled in many different directions by
Bombardetal.(2010)conductedanactionresearchstudy clinicians that did not understand their role. Support
toexploreacohortoffourdirect-entrymaster'sstudent's from upper management was considered crucial to the
CNL clinical immersion and postcertification transition successoftheirrole;withoutit,theyfearedanuncertain
experience. Participants used a variety of data collection future within their organization. Overall, the CNLs
methods (see Table 2) and content analysis to identify expressed great pride in their work advocating for
major themes defining the CNL transition experience. patients, but were concerned for their future as leaders
Themajorthemewasansweringthequestion“Whatisa at the bedside, and felt they needed greater affirmation
CNL,”whichincorporatedfoursubthemes:(a)comingto from their managers and leaders to sustain and/or
the edge, (b) trusting the process, (c) rounding the continue to grow therole.
corner, and (d) value becoming. The students struggled Stanton et al. (2011) examined the CNL role as
to answer the question they were repeatedly asked by presently implemented to determine if the educational
othercliniciansduringtheirimmersionexperience:What preparationoftheCNLcomplementstheimplementation
itwasexactlythattheyweredoing.Ittookaleapoffaith oftheroleinthehospital,homehealth,andpublichealth
for each student to overcome the uncertainty of the arena. The investigators developed a questionnaire to
clinical demands and to trust that they would meet gatherrespondent'sagreementwith19statementsabout
clinical competencies by the end of the program. There CNL competencies and relationship to their current
came a turning point for each student when they felt a clinicalposition.Thequestionnairealsocontainedopen-
senseofaccomplishmentintheiractionsandtransitioned ended questions asking respondents “to describe and
from uncertainty to confidence that they had the skills comparetheiractualroletotheCNLasenvisionedbythe
needed to improve patient processes. The students AACN.” Survey responses indicated a high degree of
describeaprocessofcontinuinggrowthaftergraduation agreement with the nine components of CNL practice:
and obtaining CNL certification to develop the clinical clinician, outcomes manager, client advocate, educator,
expertise,experience,andself-assuranceneededtofeelat information manager, systems analysis/risk anticipator,
apointofreadinesstotransitionintoaformalCNLrole. team manager, member of a profession, and lifelong
Sorbello(2010)usedahermeneuticphenomenological learner.Nosinglerespondent'sclinicalpositionincorpo-
approach to explore the meaning of leadership for ratedallnine,suggestingvariabilityintheroledepending
practicing CNLs. Ten certified CNLs were interviewed on setting, which theinvestigatorsstate conforms tothe
duringthe2009CNLSummitConferencetogathertheir description of expected role diversity within the AACN
perspectives on the following: what it was like to be a White Paper. Qualitative analysis of open-ended ques-
CNL;whatitmeanttoleadatthepointofcare;andhow tions resulted in the identification of four emerging
caring was expressed in the CNL role. Emerging themes themes of CNL practice: (a) responsibility for outcomes
of the meaning of leadership for CNLs practicing at the improvement, (b)useofevidenceasabasisforpractice,
bedside were (a) navigating safe passage, (b) making a (c) importance of mentoring and developing staff, and
CURRENTEVIDENCEBASEFORTHECLINICALNURSELEADER 113
Table1. DescriptionsintheLiteratureofCNL(orModifiedCNL)ImplementationsWithinVariousHealthCareSystemsAcrossthe
UnitedStates
Healthcare Microsystem Context of Positive outcomes Report(s) describing
setting setting(s) implementation described implementation
119-Bedacademic 26-Bed Noexecutiveleadership Patientsatisfactionscores, Bender,Mann,&Olsen,
medicalcenter progressivecare involved;oneCNLcertified RN–physicianteam 2011,Bender,Connelly,
inSanDiego unit andothershadBSNwith communicationand Glaser,&Brown,2012,
California “documentedevidenceof collaboration,staff Bender,Connelly,&
nursingexpertiseand perceptionsofa Brown,2013
leadership”and“understanding collaborativeenvironment
[that]pursuitofCNL
certificationandadvanced
degreewouldberequired”
551-Bednonprofit 39-Beddiabetes/ AACNCNLWhitePaper Homehealthreferralrates, Bowcutt,Wall,&
University gastrointestinal servedasaresourceforthe individualstoriesof Goolsby,2006
Hospitalin unit;cardiacunit “carecoordinator”role,as“no patient-specific
Augusta actualCNLprogramgraduates positiveoutcomes
Georgia yetexisted.”Bothcare
coordinatorswereNPs.Part
ofnationalpilot“todevelop
CNLcurriculumaswellas
pilottherolewithinthe
organization”
5-Hospital,1500- Approximately “Onlyexperiencednurses Multidisciplinaryrounds, Drenkard,2004
bedInova 40units receivedteamcoordinator staffrelationships,
HealthSystem throughout jobs.Thelevelofeducation physiciansatisfaction
inFairfax thesystem thatisultimatelydecided
Virginia uponfortheCNLrolewill
drivetheexperiencelevelof
thenurseinthisrole”
194-Bedfor-profit 36-Bed CNLrolesuperceded“patient Staffretention,patientand Gabuat,Hilton,Kinnaird,
St.LucieMedical progressivecare carecoordinator”rolewhile physiciansatisfaction,Joint &Sherman,2008,
CenterinSt. unit;45-bed coordinatorresponsibilities Commissioncoremeasures, Sherman,Edwards,
LucieFlorida med–surgunit changedtomore RNswithnational Giovengo,&Hilton,2009,
administrativefocus certification,HAPU Stanleyetal.,2008,
Hilton,2010
4-Hospital1100- 43-Bedmed/ “Evaluationsoccurredin LOS,personalstoriesof Hartranft,Garcia,&Adams,
bednonprofit surg-telemetry settingsinwhereCNL individualpatientcare 2007,Stanleyetal.,2008
MortonPlant unit;45-bed graduatesandstudentswere improvement,falls,CMS
MeaseHealth oncologyunit beginningtopractice” coremeasures,HAPU,
CareSystemin physiciansatisfaction
Clearwater
Florida
VATennessee Ambulatory “AllCNLshadmasterof Surgicalinfectionrates,RN Fitzpatrick&Wallace,
Valley surgeryunit; scienceinnursingdegrees hoursperpatientday,heart 2009;Harris,Walters,
Healthcare surgicalinpatient andhadsuccessfullypassed failure-specific30-day Quinn,Stanley,&McGuinn,
Systemin unit;GI theCNLcertification readmissions,Joint 2006;Hix,McKeon,&
Nashville laboratory; examination” Commissioncoremeasures, Walters,2009;Miller,2008,
Tennessee SICU;MICU; LOS,surgicalandGI Ottetal.,2009
transitionalcare cancellation/no-showrates,
unit postsurgerybloodtransfusion
rates,ICUpatientVTE
prophylaxis,participationin
restorativedining
(ifindicated)
VeteranHealth Med–surg, “VHAfacilitieswithpracticing Nursinghoursperpatient Ottetal.,2009
Administration subacute CNLSwereinvitedto day,sitterutilization,
carecenters andSICUunits participateintheevaluation falls,HAPU,CMScore
(doesnot oftheproject”;doesnot measures(heart
stateexact specifyeducation/certification failuredischarge
locations) teaching),VAP
(Continued onnextpage)
114 MIRIAMBENDER
Table1. (Continued)
Healthcare Microsystem Context of Positive outcomes Report(s) describing
setting setting(s) implementation described implementation
MaineMedical Specialcareunit; CNLstudentsassumed VentilatedpatientLOSin Poulin-Taboretal.,2008;
Centerin pediatricunit; responsibilitiesofroleduring ICU,individualstories Wiggins,2006
PortlandMaine cardiothoracic CNLimmersionatthehospital ofpatient-specific
unit;medical (present5days/week) positiveoutcomes
cardiologyunit
HunterdonMedical 3med–surg “1dayperweekto‘playinthe Improvedcollaborative Rusch&Bakewell-Sachs,
Centerin units role’whileinschool.”“The professionalrelationships 2007
FlemingtonNew CNLpositionwithbepartof
Jersey theoverallbudgetforFTEs”
aftergraduation”
BaptistHospitalin Allunitsexcept Patientcarefacilitatorrole 11a.m.discharge,CMS Sherman,Clark,&
MiamiFlorida rehab, developedfirst,usingBSN coremeasures, Maloney,2008;Harris
interventional degreeRNs.Therole“will patientsatisfaction &Roussel,2010
anddiagnostic ultimatelyincludeboth
areas,PACU, advancedpracticenursesand
radiation CNLs”(11PCFshaveenrolled
oncology intheeducationalprogram)
OSFStJoseph 46-Bedmed– “Patientcarefacilitator Falls,HAPU,patient Smith&Dabbs,2007
MedicalCenter surgunitpilot, willtransitionintoCNL” satisfaction,staffturnover,
inBloomington eventuallyall andareenrolledinaCNL LOS,dischargesbefore
Illinois unitsexcept program 11a.m.
obstetrics
321-BedFlager 43-Bedcardiac/ “Patientcarecoordinator”role Nursingjobsatisfaction, Smith,Hagos,etal.,2006;
hospitalinSt. pulmonaryunit developedsimilartoCNL, nurseretention,patient Smith,Manfredi,Hagos,
Augustine utilizingmaster's-prepared andphysiciansatisfaction, Drummond-Huth,&
Florida RNs.“Projected contractlaborusage, Moore,2006
implementationoftheCNL LOS,restraintuse,falls
role”throughpartnershipwith
NEFloridaUniversity
733-Bednonprofit 17-Bed “CNLstudent's3-month Painmanagement,nurse Stanleyetal.,2008
Shands oncologyunit immersionexperienceserved responsetocalllightand
Jacksonville astheactivityaroundwhich overallnursingcare
AcademicHealth therolewasevaluated” patientsatisfaction
Centerin
Jacksonville
Florida
336-BedVirginia ExtendedLOS Roledeveloped“drawingfrom LOS,lettersofpatient Tachibana&Nelson-
MasonMedical patients(N6days) definitionoftheCNLas careexperiences Peterson,2007
CenterinSeattle throughout outlinedbytheAACN”and“a
Washington thehospital nurseeducatedatthegraduate
level”
St.VincentHospital “Systemservice Clinicalimmersionservedas Coordinationofmedication Stantonetal.,2008,
inBirmingham linebased, CNLproject.“Students administrationprocessfor Lammon,Stanton,&
Alabama implementcare successfullycompletedthe patientsatriskformedical Blakney,2010
managementat CNLcertification.CNLs[will] error
thepointof implementtheroleintheir
care” respectiveagencies”
AlabamaDeptof “Alllevelsand Stateandcommunity Stantonetal.,2008,
PublicHealth aspectsofthe collaborativecoordination Lammon,Stanton,&
community” forpandemicinfluenza Blakney2010
publichealth planning
areasinAlabama
FayetteMedical Allpatientsat Trackingofpatients Stantonetal.,2008,
Centerin riskforHAPUin throughoutstay,protocol Lammon,Stanton,&
FayetteAlabama aruralhospital education Blakney2010
AlacareHome Strokepatients Patient/caregiverknowledge Stantonetal.,2008,
Healthand inthehomecare ofdiseasemanagementskills Lammon,Stanton,&
Hospicein setting andfunctionalstatus Blakney2010
Birmingham
Alabama
CURRENTEVIDENCEBASEFORTHECLINICALNURSELEADER 115
Table1. (Continued)
Healthcare Microsystem Context of Positive outcomes Report(s) describing
setting setting(s) implementation described implementation
TuscaloosaVA SICU,MICU, VAPrates,compliancewith Stantonetal.,2008,
MedicalCenter CCU glycemiccontrolprotocol, Lammon,Stanton,&
inBirmingham rapidresponseutilization, Blakney2010
Alabama CRBSIrates
LOS=lengthofstay,CMS=centersformedicare&medicaidservices,VAP=ventilatorassociatedpneumonia,BSN=bachelorofscienceinnursing,
NP=nursepractitioner,HAPU=hospital-acquiredpressureulcers,ICU=intensivecareunit,MICU=medicalintensivecareunit,SICU=surgical
intensivecareunit,CCU=coronarycareunit,GI=gastrointestinal,VTE=venousthromboembolismprophylaxis,PACU=postanesthesiacareunit,
CRBSI=catheter-relatedbloodstreaminfection.
(d) involvement in special organizational projects. The and (e) cautious about the future. CNLs described the
investigatorsconcludethattheCNL“travelswell”andis continuous need to explain their role to other practi-
adaptable to a wide variety of clinical microsystems and tioners, sometimes “at least 10 times each day.” They
thatevidence-basedpractice,outcomesmanagement,and describethisasaresultofinconsistentengagementfrom
staffeducation are criticalaspects of the role. executive leadership in the pilot project, causing
Sherman(2008)usedagroundedtheorymethodology confusion androle overlap for some of the CNLs within
toexplorefactorsthatinfluencedthedecisionsof10chief theirpracticesites.AlthoughtheCNLswereclearlyable
nursingofficers(CNOs)topromoteinvolvementoftheir to articulate the value of their work, they also described
organizations in the CNL project. Five major themes theconstantchallengesofstayingfocusedontheroleand
emerged to form a framework explaining organizational not getting drawn into direct patient care because
participationintheCNLproject:(a)organizationneeds, managers or other leaders did not see the value of their
(b) desire to improve patient care, (c) opportunity to work. This challenge to keep the role “pure” was also
redesign care delivery, (d) promotion of professional recognizedthroughthevariationinCNLroleimplemen-
development of nursing staff, and (e) potential to tation itself, depending on microsystem needs or
enhance physician–nurse relationships. The CNOs de- organizational priorities. The CNLs felt that this lack of
scribedtheneedfortheirorganizationstodoabetterjob consistent role delineation created role confusion and
complying with regulatory requirements and viewed the wasabarriertowideracceptance.Overall,theCNLsfelt
CNLaswaytoensurecomplianceatthepointofpractice. that no matter the challenges, their education had given
They envisioned the CNL as an “air traffic controller” thema“phenomenalskillset”thatmadetheminvaluable
who would reduce the chaos that is the current state of to organizationsin a variety of positions(if nota formal
clinical practice and help remedy undiagnosed systemic CNL role). CNLs who felt most successful in their role
problems that showed up as adverse patient outcomes. had the greatest involvement of the CNO and unit
They felt CNL leadership skills would be necessary to
facilitate redesign of chaotic care delivery systems not
functioning as needed to provide seamless patient care.
Table2. CNCJobAnalysisDescriptiveStatisticsofRespondents'
CNOshopedtheCNLswouldhelpimprovetheimageof
SubdomainWeights
nursingthroughmentoring, rolemodelingbest practice,
and encouraging professionalism at the bedside. Com- Subdomain Min% Max% Mean %
munication was seen as essential to improving care Evidence-basedpractice 0 40 9.20
delivery, and CNOs predicted that the continuous CNL Interdisciplinarycommunication 0 30 8.15
presence on the unit would improve cross-disciplinary andcollaborationskills
communication. Overall, the investigator found that the Qualityimprovement 0 35 7.71
identifiedthemesaligned wellwiththeAACNvisionfor IntegrationofCNLrole 0 20 6.64
the role and furthermore argued that this alignment of Illnessanddiseasemanagement 0 30 6.45
Teamcoordination 0 25 6.37
goals between education and practice may be a critical
Lateralintegrationofcareservices 0 15 6.13
factorin the success of the CNL project.
Advancedclinicalassessment 0 15 5.99
Sherman (2010) also conducted an interpretive
Healthpromotionanddisease 0 20 5.96
phenomenology study to describe the role transition
preventionmanagement
experiences of 71 CNLs as they pioneered the role in
Horizontalleadership 0 20 5.79
diverse practice settings across the country. Certified Knowledgemanagement 0 15 5.14
CNLsansweredopen-endedquestionsduringsemistruc- Ethics 0 84 5.10
tured telephone interviews. Interviews were taped, Healthcareadvocacy 0 11 4.89
transcribed, coded, and categorized into emerging Healthcaresystems 0 10 4.53
themes. Five major themes were identified regarding Healthcareinformatics 0 20 4.29
the CNL role transition experience: (a) staying at the Healthcarefinanceandeconomics 0 10 4.07
Healthcarepolicy 0 15 3.60
bedside, (b) explaining who we are, (c) keeping things
from falling through the cracks, (d) proving our value, AdaptedfromCNC,2011,printedwithpermissionfromtheCNC.
116 MIRIAMBENDER
manager as champions of change during the implemen- the Tampa Bay Florida area. Staff nurses worked on
tation phase. telemetry, urology, orthopedic, and medical–surgical
Klich-Heartt(2010)exploredentry-levelmaster'sCNL units employing CNLs or similar units that did not
graduates utilization of end-of-program competencies in have CNLs. Staff nurses completed five survey instru-
their current nursing practice through an investigator- ments: (a) Nursing Stress Scale (NSS) to measure work-
developed “Entry-Level CNL” survey, which used CNL relatednursingstress;(b)NursingWorkRelatedIndex–
end competencies as a source for items. The survey also Revised (WRS) to measure job satisfaction; (c) Medical
included open-ended questions asking about CNL's OutcomesInventoryStudyShortForm(MOI)tomeasure
ability to apply elements of educational competencies in overall nurse well-being; (d) Anticipated Turnover Scale
their dailypractice.ThesurveywassentthroughSurvey (ATS) to measure nursing turnover; and (e) an investi-
Monkeyinearly2010toallrecentgraduates(n=163)of gator-developeddemographicsurvey.Independentttests
SonomaStateUniversityandUniversityofSanFrancisco and multiple regressions were used to analyze results.
entry-level master's CNL programs. Fifty seven (35%) Major findings included a significant difference between
graduatesresponded.Thirty-sixpercentwerestaffnurses groups on the “mental health” subscale of the MOI's
and 40% were in “charge or leadership roles.” Overall, Mental Health Summary Score (t = −2.34, P = .021),
more than half of the respondents felt they were able to indicating nurses working on a CNL unit were happier
apply CNL competencies within their current nursing and less depressed than nurses not working on a CNL
position, and 67% reported assimilating research-based unit. There was also a significant difference between
evidencetoimprovetheirunitoutcomes.Mostwerealso groups on ATS score (t = 2.01, P = .047), indicating
taking part in facility-wide committees and “having an nurses working on a CNL unit had less anticipated
impact on client outcomes.” Common themes of open- turnover than nurses not working on a CNL unit.
ended responses included the following: awareness of Regression analysis showed employment on a CNL unit
theirnovicestageasanurse;unfamiliarityorresistanceto was associated with greater intention to stay on the unit
theCNLrolebytheiremployers;andarealizationofthe (β = −2.5, P = .048). The R2 for the model was not
potentialfortheCNL'sskillsetastheircareeradvanced. provided,soitisunclearhowmuchvariationthemodel
Moore and Leahy (2012) developed a “CNL Transi- accounted for. The investigator notes that the improved
tions into Practice” questionnaire, which included 13 mentalhealthofstaffnursesworkingonCNLunitsmay
broad open-ended questions designed to explore CNL's berelatedtothesocialsupporttheCNLprovidesaspart
experience implementing the role in their practice. The of their job workflow. The investigator also notes social
survey was administered via Survey Monkey to 24 support has been linked to greater job motivation and
certified CNLs currently practicing in the role (a date mayexplainwhypresenceofasupportiveCNLrolewas
rangewasnotprovided).Qualitativecontentanalysiswas correlated with decreased anticipated turnover. The
used to identify themes of CNL practice around the 13 investigator concludes that the CNL may be influential
questions. For questions about role introduction, re- inreducingepidemicratesofnursingstressandturnover
spondentswereequallydistributedindescribingeithera and should befurther investigated.
structured organizational rollout or a more ad hoc Bender et al. (2012) conducted a quasi-experimental
practice introduction. For questions about role imple- interruptedtimeseriesstudytomeasurepatientsatisfac-
mentation, most respondents described a lack of role tion with multiple aspects of care 10 months before and
clarity,and43%describedbeingclinicallyoverburdened 12 months after integration of a CNL role on a
because of this lack of role delineation. Overall, 82% progressive care unit, compared to a similar unit that
believed that their role improved care quality while didnothaveCNLs.Thesettingwasa26-bedunitwithin
remaining close to the bedside. Staff nurses, although a 119-bed academic medical center. Data were obtained
appreciating the extra support, still did not understand from Press Ganey surveys, and analysis was completed
what the role was about. For questions about role using a publicly available program for short time series
sustainability, most respondents felt executive nursing data streams. CNL implementation was correlated with
leadership would be essential to the role's continuing significantly improved patient satisfaction with admis-
success, although a worrying 61% of respondents sion processes (r = +.63, P = .02) and nursing care (r =
identified nurse administrators as having the greatest +.75, P = .003), including skill level (r = .83, P = .003),
resistancetotherole. Thirty-nine percent also identified and keeping patients informed (r = .70, P = .003), and
theneedforamore defined andstructuredroleinorder “attention to requests” (r = .68, P = .01). Control data
for long-termsustainability. showed no significant changes in patient satisfaction
measures throughout the study time frame. The in-
Quantitative CNL Research
vestigators note significant improvements in scores
Kohler (2010) conducted an ex post facto study to corresponded with CNL accountability for care coordi-
determinetherelationshipbetweentheCNLroleand(a) nation and interdisciplinary collaboration, but the
work-relatedstress,(b)jobsatisfaction,(c)qualityoflife, introductionofmultidisciplinaryroundingandprocesses
and (d) anticipated turnover of acute care staff nurses leading to better progression toward discharge goals did
working on CNL and non-CNL units. Participants not impact patient satisfaction with their discharge or
included 94 staff RNs from three nonprofit hospitals in their physician. The investigators conclude the data
CURRENTEVIDENCEBASEFORTHECLINICALNURSELEADER 117
Table3. QualitativeStudiesontheCNLRole
Primary Study
investigator purpose/aims Design Sample Data collection Analysis Major findings
Sherman, Explorethe StraussandCorbin Convenience One-hour Coding,core Fivemajorthemes
2008 drivingfactors GroundedTheory sampleof10(of semistructured categories emergedtoforma
thatinfluenced atotalof25 face-to-face developed frameworkthat
thedecisions invitedto interviewsusing explains
ofCNOsto participate) 8open-ended organizational
promotethe CNOsfrom questions participationin
involvement healthcare CNLproject.(a)
oftheir agenciesin organizationneeds,
organizations Florida (b)desireto
intheCNL participatingin improvepatient
project theCNLproject care,(c)
opportunityto
redesigncare
delivery,(d)
promotionof
professional
developmentof
nursingstaff,(e)
potentialto
enhancephysician–
nurserelationships
Stanton, Examinethe Exploratorysurvey EightUniversity Investigator- Frequency Overallfindings
Barnett,& CNLroleas withclosedand ofAlabamaCNL developed distributionsof showthereis
Williams, itispresently open-ended graduates questionnaire closed-ended disparitybetween
2011 implemented responses (mailedwith responsesand theCNLroleas
andwhether stampedreturn qualitative taughtandhowitis
theeducational envelope) content actually
preparation with19 analysisof implementedinany
oftheCNL statements open-ended particularsetting.
complements abouttheCNL responses Mostrespondents
theimplementation roleaskingfor functionas
oftheroleinthe respondent's educator,data
hospital,home agreement analysisand
health,and between effectingchangein
publichealth statementand organization.Most
arenas theiractual respondentswere
position not(oronly
descriptionona somewhat)
4-pointLikert involvedwithcare
typescale.An coordination,
unspecified financialimpact
numberofopen- analysis,orethical
endedquestions guideline
askingrespondents development.
“todescribeand Themesfrom
comparetheir open-ended
actualroleto responsesinclude
theCNLroleas (a)responsibility
envisionedby foroutcomes
theAACN” improvement,(b)
useofevidenceasa
basisforpractice,
(c)importanceof
mentoringand
developingstaff,
and(d)
involvement
inspecial
organizational
projects
(Continued onnextpage)
118 MIRIAMBENDER
Table3. (Continued)
Primary Study
investigator purpose/aims Design Sample Data collection Analysis Major findings
Bombard Analyzethe Actionresearchas Fourstudents, Reflective Content Dominanttheme:
etal.,2010 experience describedby clinicalfaculty journals,faculty analysis,theme howtoanswerthe
ofdirect Holterand leader,writing notesofseminar development question“whatisa
entrymaster's Schwartz-Barcott consultant discussions, CNL.”Subthemes
studentsinthe studentreflections include:comingto
firstcohortto onexperience theedge,trusting
completethe writtenafter theprocess,
CNLcurriculum graduation, roundingthe
andsitforCNL transcriptsof4 corner,value
certification analyticdiscussion becoming
sessions
Sherman, Describethe Interpretive 71certified Semistructured Opencoding Themesexplaining
2010 roletransition phenomenology CNLs telephone intocategories theCNLrole
experiences nationwide interviewswith andthemes transition
of71CNLsas workinginthe 9open-ended experience
theypioneered roleinpractice questions included:(a)staying
therolein settings atthebedside,(b)
practicesettings explainingwhowe
are,(c)keeping
thingsfromfalling
throughthecracks,
(d)provingour
value,and(e)
cautiousabout
thefuture
Sorbello, Whatisthe VanManen's 10certified 60-Minute “selectiveor Essential themes
2010 meaningof phenomenology CNLSthat unstructured highlighted of meaning that
leadershipas approach respondedto (using“story reading” leading at the
experiencedby emailinvitations method”) approachas bedside has for
CNLs?Whatis forparticipation interviewswith definedbyVan CNLs include:
itliketobea duringthe 8in-personand Manentoform (a)navigatingsafe
CNL;whatdoes nationalCNL 2over-the- thematic passage,(b)making
itmeantolead Conferencein phone;field groups adifferenceevokes
atthepointof NewOrleans, notes, pride,(c)bringing
care;howis Louisiana investigator thebedsidepoint
caringlivedin journal ofview,(d)
theroleofthe knowingthe
CNL? patientascaring
person,(e)living
caringwithnurses,
and(f)needingto
beknown,
understoodand
affirmed
Moore& Explorethe Qualitative, 24certified 24-Item Qualitative Themesfor
Leahy, experiencesof descriptivedesign CNLsidentified Investigator- content implementingthe
2012 CNLsasthey through developed“CNL analysis newCNLrole
launchedthe attendancelist Transitioninto included:(a)
CNLroleinthe of2009CNL Practice systematicvs.
practicesetting Summit Questionnaire,” unplannedrole
Conference broadopen- introduction,(b)
endedquestions lackofroleclarity
developed andoverburdened
throughreview practice,(c)
ofliteratureand improvedcare
CNL-educator quality,and(d)need
expertise fornurseleader
supportandmore
structuredrole
description