Miriam Bender

Interdisciplinary collaboration: The role of the clinical nurse leader

AIMS   To explore the feasibility and acceptability of a clinical nurse leader (CNL) role to improve interdisciplinary collaboration (IC) within a fragmented acute-care microsystem. BACKGROUND   Fragmented patient care is associated with preventable adverse healthcare outcomes. IC decreases fragmentation and improves patient care quality. The CNL role is theorized to provide the necessary leadership and competency skill base to impact IC at the optimal organizational level, the point of care where most healthcare decisions are made. METHODS   This study used a descriptive non-experimental design. CNL daily workflow was developed to target empirical determinants of IC. Descriptive data were collected from multiple stakeholders using an investigator-developed survey. RESULTS   Findings indicate the integration of the role is feasible and acceptable to the microsystem healthcare team. CONCLUSIONS   Preliminary evidence suggests the CNL role may be an effective intervention to facilitate IC. More research is needed to support the CNL roles association with microsystem IC. IMPLICATIONS FOR NURSING MANAGEMENT   The CNL role presents an innovative opportunity for clinical and administrative leadership to partner together to redesign a healthcare delivery system and improve patient care quality.

Clinical nurse leader impact on microsystem care quality

Background:The current fragmented healthcare system, characterized by a lack of collaborative, patient-centered care processes, creates significant barriers to providing quality patient care. The clinical nurse leader (CNL) is theorized to provide clinical leadership at the point-of-practice to maintain cross-disciplinary collaborative processes that lead to integrated quality care. Objectives:The aim of this study was to assess the impact of CNL integration into an acute care microsystem on care quality, as measured by patient satisfaction with care. Methods:A short interrupted time series design was used to measure patient satisfaction with multiple aspects of care 10 months before and 12 months after integration of the CNL role on a progressive care unit, compared with a control unit. Data were obtained from Press Ganey surveys, and analysis was completed using a publicly available program for short time series data streams. Results:Clinical nurse leader implementation was correlated with significantly improved patient satisfaction with admission processes (r = + .63, p = .02) and nursing care (r = +.75, p = .004), including skill level (r = .83, p = .003) and keeping patients informed (r = .70, p = .003). There was no significant correlation with improved patient satisfaction with physician care (r = .31, p = .14) or discharge processes (r = .33, p = .23) postimplementation. Control data showed no significant changes in patient satisfaction measures throughout the study time frame. Discussion:The positive correlation between CNL-mediated collaborative care processes and improvements in patient satisfaction with care quality provides empirical evidence of outcomes achievable through CNL implementation. Research is needed to explore the full range of achievable outcomes and to determine the specific processes by which these outcomes are realized.

The Current Evidence Base for the Clinical Nurse Leader: A Narrative Review of the Literature

The clinical nurse leader (CNL) is a relatively new nursing role, introduced in 2003 through the 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 methodologically diverse CNL evidence base. The review included 25 implementation reports, 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 quality wherever it is implemented, CNLs are still struggling to define the role to themselves and to the health care spectrum at large. Although the AACN CNL White Paper provides a concise 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.

Clinical Nurse Leader Integration Into Practice: Developing Theory To Guide Best Practice

Numerous policy bodies have identified the clinical nurse leader (CNL) as an innovative new role for meeting higher health care quality standards. Although there is growing evidence of improved care environment and patient safety and quality outcomes after redesigning care delivery microsystems to integrate CNL practice, significant variation in CNL implementation has been noted across reports, making it difficult to causally link CNL practice to reported outcomes. This variability reflects the overall absence in the literature of a well-defined CNL theoretical framework to help guide standardized application in practice. To address this knowledge gap, an interpretive synthesis with a grounded theory analysis of CNL narratives was conducted to develop a theoretical model for CNL practice. The model clarifies CNL practice domains and proposes mechanisms by which CNL-integrated care delivery microsystems improve health care quality. The model highlights the need for a systematic approach to CNL implementation including a well-thought out strategy for care delivery redesign; a consistent, competency-based CNL workflow; and sustained macro-to-micro system leadership support. CNL practice can be considered an effective approach to organizing nursing care that maximizes the scope of nursing to influence the ways care is delivered by all professions within a clinical microsystem.

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.

Leading transformation: implementing the clinical nurse leader role.

It has become a national priority to have an effective care delivery system for the 21st century. Improving the quality of care and ensuring that the care delivered in a patient-centered framework are goals for many organizations. Nursing practice will be at the core of these changes, working at the point of service as well as at the organizational level. In response to the need for nursing to realign our practices in accordance with the new healthcare mandate, the American Association of Colleges of Nursing has developed the clinical nurse leader (CNL) role. The CNL is a master’s-prepared RN educated to enhance the efficiency of care delivery and facilitate the coordination of care at the bedside through effective collaboration with all healthcare providers. Clinical nurse leader competencies align with key messages highlighted in the Institute of Medicine’s 2010 report on The Future of Nursing, including the need for a highly educated nursing workforce practicing at their full scope, and for RNs to become full partners with physicians and other health professionals in redesigning healthcare. The CNL role has been demonstrated to improve patient outcomes, but it has not been widely adopted throughout the country. This article describes how a progressive care unit (PCU) redesigned its care delivery system to implement the CNL role, using Kotter’s Eight Change Phases model as a guide.

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.

A Practice Theory Approach to Understanding the Interdependency of Nursing Practice and the Environment: Implications for Nurse-Led Care Delivery Models

Nursing has a rich knowledge base with which to develop care models that can transform the ways health is promoted and valued. However, theory linking the environment domain of the nursing metaparadigm with the real-world environments where nurses practice and patients experience their health care is tenuous. Practice theory is used to foreground the generative role of nursing practice in producing environments of care, providing the basis for a metaparadigm relational proposition explicitly linking nursing practice and environment metaparadigm domains. A theoretical and empirical focus on the significance of nursing practice dynamics in producing environments of care that promote health and healing will strengthen present and future nursing care models.

Clinical Nurse Leader–integrated Care Delivery: An Approach to Organizing Nursing Knowledge Into Practice Models That Promote Interprofessional, Team-based Care

J Nurs Care Qual Vol. 32, No. 3, pp. 189–195 c 2017 Wolters Kluwer Health, Inc. All rights reserved. Copyright Commentary In this commentary, a clinical nurse leader (CNL) reflects on the role of the CNL in promoting continuity of care. Clinical Nurse Leader–Integrated Care Delivery An Approach to Organizing Nursing Knowledge Into Practice Models That Promote Interprofessional, Team-Based Care Miriam Bender, PhD, RN, CNL T HE STORY told by Segal 1 in “Looking for Continuity of Care” is unfortunately typical for many patients and families work- ing their way through today’s health care system. The problem expressed so articu- lately by Segal is a distinct lack of the critical health care communication and collaboration practices that drive continuity of care. This state of affairs continues despite the fact that we have an extensive literature defining what care quality should look like in terms of patient-centeredness, timeliness, safety, Author Affiliation: Sue and Bill Gross School of Nursing, University of California, Irvine. The author declares no conflict of interest. Correspondence: Miriam Bender, PhD, RN, CNL, Sue and Bill Gross School of Nursing, University of Cal- ifornia, Irvine, 252C Berk Hall, Irvine, CA 92697 (miriamb@uci.edu). Accepted for publication: January 10, 2017 Published ahead of print: February 16, 2017 DOI: 10.1097/NCQ.0000000000000247 efficiency, effectiveness, and equity. 2 One issue is current care delivery infrastructures, which actively hinder interprofessional collaborative care processes. 3,4 As Segal’s experience exemplified so acutely, the majority of today’s care environments are structured so that nurses, physicians, other care providers, and administrative managers and leaders deliver or ensure quality care via mutually exclusive processes, with unique expected outcomes that are informed by distinct disciplinary curricula and training. Researchers and health care leaders are ac- tively seeking ways to redesign care systems in ways that overcome these critical chal- lenges. The purposes of this article are to (a) describe current conceptualizations of in- terprofessional communication and collabo- ration; (b) summarize the literature on clin- ical leadership, a mode of clinical behavior to promote engagement in specific practices; and (c) delineate current theory and evidence about clinical nurse leader (CNL)–integrated care delivery, an approach to structuring Copyright