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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 eScholarship.org Powered by the California Digital Library University of California 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

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