Marjory Williams

Growing and Sustaining the Clinical Nurse Leader Initiative: Shifting the Focus From Pioneering Innovation to Evidence-Driven Integration Into Healthcare Delivery.

The Clinical Nurse Leader (CNL) initiative has been characterized by innovation. While an innovation framework for diffusing CNL practice remains relevant, generalizable evidence of effectiveness is necessary to sustain nationwide momentum. A framework is proposed in this department for a national-level CNL research collaborative linking research, policy, education, and practice stakeholders in an ongoing partnership to advance CNL evidence, education, policy, and practice.

Clinical Nurse Leader Integrated Care Delivery to Improve Care Quality: Factors Influencing Perceived Success

PURPOSE Clinical nurse leader(TM) (CNL)-integrated care delivery is a new model for organizing masters-level nursing clinical leadership at the microsystem level. While there is growing evidence of improved patient care quality and safety outcomes associated with CNL practice, organizational and implementation characteristics that influence CNL success are not well characterized. The purpose of this study was to identify organization and implementation factors associated with perceived success of CNL integration into microsystem care delivery models. METHODS A survey was developed and administered to a nationwide sample of certified CNLs and managers, leaders, educators, clinicians, and change agents involved in planning or integrating CNLs into a health systems nursing care delivery model. Items addressed organizational and implementation characteristics and perceived level of CNL initiative success. Generalized linear modeling was used to analyze data. RESULTS The final sample included 585 respondents. The final model accounted for 35% of variance in perceived CNL initiative success, and included five variables: phase of CNL initiative, CNL practice consistency, CNL instructor or preceptor involvement, CNL reporting structure, and CNL setting ownership status. CONCLUSIONS CNL initiative success is associated with modifiable organizational and implementation factors. CLINICAL RELEVANCE Study findings can be used to inform the development of successful implementation strategies for CNL practice integration into care delivery models to improve care quality outcomes.

Diffusion of a Nurse-led Healthcare Innovation: Describing Certified Clinical Nurse Leader Integration Into Care Delivery

BACKGROUND: The Clinical Nurse Leader™ (CNL) initiative is in its 2nd decade. Despite a growing theoretical and empirical body of CNL knowledge, little is known about CNLs themselves or where and how their competencies are being integrated into care delivery across the country. OBJECTIVE: The aim of this study was to describe certified CNL characteristics and roles as part of a larger study validating a model for CNL practice. METHODS: This study used a descriptive analysis of survey data from a national sample of certified CNLs. RESULTS: Survey response rate was 19%. Sixty percent have greater than 10 years of RN experience, and 75% have additional specialty certifications. Fifty-eight percent are practicing in a formal CNL role and report a high degree of accountability for all 9 CNL essential competencies. CONCLUSIONS: Findings help understand the extent of CNL adoption and spread across the country and the level to which the initial vision of CNL practice is being achieved.

Promoting a Strategic Approach to Clinical Nurse Leader Practice Integration.

The Office of Nursing Services of the Department of Veterans Affairs (VA) piloted implementation of the clinical nurse leader (CNL) into the care delivery model and established a strategic goal in 2011 to implement the CNL role across the VA health care system. The VA Office of Nursing Services CNL Implementation and Evaluation (CNL I&E) Service was created as one mechanism to facilitate that goal in response to a need identified by facility nurse executives for consultative support for CNL practice integration. This article discusses strategies employed by the CNL I&E consultative team to help facility-level nursing leadership integrate CNLs into practice. Measures of success include steady growth in CNL practice capacity as well as positive feedback from nurse executives about the value of consultative engagement. Future steps to better integrate CNL practice into the VA include consolidation of lessons learned, collaboration to strengthen the evidence base for CNL practice, and further exploration of the transformational potential of CNL practice across the care continuum.

Self-sanitizing copper-impregnated surfaces for bioburden reduction in patient rooms

HighlightsCopper‐impregnated tray tables had lower microbial burden than standard material.Bioburden difference between surfaces was statistically significant beyond 24 hours.The mean bioburden on copper surface was 81% lower at hour 30 than non‐copper. &NA; Novel self‐sanitizing copper oxide‐impregnated solid surfaces have the potential to influence bioburden levels, potentially lowering the risk of transmission of pathogens in patient care environments. Our study showed persistently lower microbial burden over a 30‐hour sampling period on a copper‐impregnated tray table compared with a standard noncopper surface in occupied patient rooms after thorough initial disinfection.

Lack of Association Between Surface Disinfection and Fluorescent Marker Score

Abstract Background The Centers for Disease Control and Prevention (CDC) recommend that hospitals ensure compliance with cleaning and disinfection procedures. Environmental Management Service (EMS) coordinators have used multiple methods to gauge effectiveness of cleaning activities. These methods include visual inspection, Adenosine Triphosphate (ATP) bioluminescence markers, fluorescent markers, and microbiological sampling. Although microbiological sampling is considered the “gold standard,” it is expensive and time consuming; therefore, alternative methods such as fluorescent markers are more commonly used. The purpose of this study was to determine whether fluorescent clean score was associated with a clean surface as determined by microbiological sampling. Methods The project was conducted at a 120-bed hospital within the Central Texas Veterans Healthcare System (CTVHCS). Rooms selected for inclusion were marked with a fluorescent marker in predetermined locations by a member of the research team. When the EMS staff person completed the routine cleaning process a member of the research team recorded the fluorescent score and obtained microbiological samples from the room. The aerobic bacterial colony (ABC) count for pre-cleaning and post-manual cleaning was also categorized into “clean” and “not-clean” categories, where clean was defined as ABC counts <2.5 CFU/cm2. Results A chi-squared test of independence revealed that there was no association between surfaces considered “clean” according to ABC criteria and “clean” according to fluorescent marker score, chi-square = 1.6167, df = 1, P = 0.20. A mixed effects logistic regression model showed that fluorescent clean score was not a significant predictor of a clean surface as defined by the <2.5 CFU/cm2 criteria (P = 0.96). Conclusion While the fluorescent marker has been shown to be useful for determining if a surface has been wiped, our results show that fluorescent marker score may not be a good proxy for assessing surface disinfection. Our results suggest that fluorescent markers only determine if the manual process of wiping has been conducted without taking into account other variables that play a role in disinfecting the surface. Disclosures C. Jinadatha, Xenex healthcare Services: CRADA, Research support

Does pulsed-xenon ultraviolet disinfection add additional value to manual cleaning?

Abstract Background Novel disinfection tools have been used to supplement standard hospital cleaning protocols. This study was conducted to determine whether the addition of Pulsed Xenon Ultraviolet disinfection (PX-UV) increased the effectiveness of manual cleaning with four different environmental cleaning and disinfecting agents and how their performance compared with the industry standard of sodium hypochlorite 10%. Methods Research staff collected 600 pre-clean, post-clean, and post-clean + PX-UV environmental samples of aerobic bacterial colonies (ABC) and MRSA from five high touch surfaces (bedrail, call button, toilet seat, bathroom grab rail, tray table). The PX-UV device was used three times - one 5 minute cycle on each side of the patient bed and one 5 minute cycle in the restroom. Results Wilcoxon signed-rank tests showed post-clean ABC counts were significantly different from post-clean + PX-UV clean counts for soap and water (P < 0.001), quaternary ammonium compound (P < 0.001), and hydrogen peroxide (P < 0.001), but not for sodium hypochlorite 10% (P = 0.78). A negative binomial mixed regression model showed that post-clean + PX-UV ABC counts for Soap and water were 8.6 times higher than post-clean ABC counts for sodium hypochlorite 10% solution, holding all other factors constant, P = 0.001. Post-clean ABC counts for QAC + UV were 6 times higher than post-clean ABC counts for sodium hypochlorite 10% solution, holding all other factors constant, P = 0.004. A Kruskal–Wallis test indicated there was no statistically significant difference in MRSA counts between cleaning chemicals at post-clean (P = 0.1563) or post-clean + UV (P = 0.337), indicating that the cleaning chemicals performed equally well at each stage. UV further statistically significantly lowered MRSA counts beyond the post-clean level only for the quaternary ammonium compound group (P = 0.0073). Conclusion The addition of PX-UV significantly improves disinfection for soap and water, hydrogen peroxide, and quaternary ammonium compound, but not for sodium hypochlorite 10%. This improvement does not bring microbial levels to those seen when using sodium hypochlorite 10% alone. Disclosures C. Jinadatha, Xenex Healthcare Services: CRADA, Research support

Does cleaning time matter? A study to determine the effect of unlimited vs limited time for terminal disinfection

Abstract Background Although the national target for the amount of time dedicated to cleaning a hospital room following patient discharge is 45 minutes, there is no conclusive evidence that cleaning duration is related to the quality of clean in terms of microbial load. Using data from a larger study on hospital room disinfection we examined the relationship between manual cleaning time and microbial burden as assessed by aerobic bacterial colony (ABC) count on high-touch surfaces. Methods Six hundred pre-clean and post-clean samples were taken from 5 different high-touch surfaces (bedrail, tray table, call button, toilet seat, and bathroom handrail) in 44 different patient rooms. Three cleaning time categories were studied: Time limited to 25 minutes; unlimited cleaning time where the housekeeper took <45 minutes; and unlimited cleaning time where the housekeeper took ≥45 minutes. The relationship between cleaning time category and post-manual clean ABC count was assessed using a conditional inference regression tree that was modeled for the outcome variable ABC count and the predictors cleaning time category and other potential confounders. Results There was no difference in ABC count for hydrogen peroxide and sodium hypochlorite 10% between the different categories of cleaning time. For quaternary ammonium compound and soap and water, the limited cleaning time category showed lower ABC counts than the unlimited time categories for samples taken from isolation rooms, P = 0.009. For 150 soap and water samples, 61 showed an increase in ABC count from the pre-clean sample to post-clean sample. Conclusion Cleaning time was not related to post-clean ABC count for sodium hypochlorite 10% or Hydrogen Peroxide. Limited cleaning time was more effective in lowering ABC counts for quaternary ammonium compound and for soap and water. For soap and water, post-clean ABC counts were actually higher than pre-clean ABC counts for numerous samples. This may be due to the spreading organisms across the surface while cleaning, without adequate disinfection. Disclosures C. Jinadatha, Xenex Healthcare Services: CRADA, Research support

Developing the Clinical Nurse Leader Survey Instrument

Clinical nurse leader (CNL)–integrated care delivery is an emerging nursing model, with growing adoption in diverse health systems. To generate a robust evidence base for this promising nursing model, it is necessary to measure CNL practice to explicitly link it to observed quality and safety outcome improvements. This study used a modified Delphi approach with an expert CNL panel to develop and test the face, content, and construct validity of the CNL Practice Survey instrument.

A Clinical Nurse Leader (CNL) practice development model to support integration of the CNL role into microsystem care delivery

The Veterans Health Administration (VHA) Office of Nursing Services (ONS) was an early adopter of Clinical Nurse Leader (CNL) practice, generating some of the earliest pilot data of CNL practice effectiveness. In 2011 the VHA ONS CNL Implementation & Evaluation Service (CNL I&E) piloted a curriculum to facilitate CNL transition to effective practice at local VHA settings. In 2015, the CNL I&E and local VHA setting stakeholders collaborated to refine the program, based on lessons learned at the national and local level. The workgroup reviewed the literature to identify theoretical frameworks for CNL practice and practice development. The workgroup selected Benner et al.s Novice-to-Expert model as the defining framework for CNL practice development, and Bender et al.s CNL Practice Model as the defining framework for CNL practice integration. The selected frameworks were cross-walked against existing curriculum elements to identify and clarify additional practice development needs. The work generated key insights into: core stages of transition to effective practice; CNL progress and expectations for each stage; and organizational support structures necessary for CNL success at each stage. The refined CNL development model is a robust tool that can be applied to support consistent and effective integration of CNL practice into care delivery.