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(1)

Miriam

 

Bender,

 

PhD

 

RN

Developing

 

a

 

Clinical

 

Nurse

 

Leader

 

Practice

 

Model

(2)

Background

The

 

American

 

health

 

care

 

system

 

as

 

currently

 

structured,

 

is

 

characterized

 

by

 

fragmented

 

care

 

delivery

 

systems

 

lacking

 

formal

 

interdisciplinary

 

collaborative

 

processes

Consequences

 

include

 

errors

 

in

 

clinical

 

practice

 

and

 

preventable

 

adverse

 

patient

 

outcomes,

 

such

 

as

 

increased

 

mortality,

 

morbidity,

 

readmission

 

rates,

 

lengths

 

of

 

stay,

 

and

 

care

 

costs

 

Professional,

 

policy

 

and

 

educational

 

organizations

 

have

 

recognized

 

the

 

need

 

to

 

transform

 

the

 

healthcare

 

workplace

 

to

 

better

 

provide

 

safe,

 

patient

 

centered,

 

and

 

(3)

Clinical Nurse Leader Initiative

In

 

response

 

to

 

this

 

need,

 

the

 

American

 

Association

 

of

 

Colleges

 

of

 

Nursing

 

(AACN)

 

spearheaded

 

the

 

development

 

of

 

the

 

Clinical

 

Nurse

 

Leader

 

(CNL)

2003

 

first

 

White

 

Paper

 

published

Educational and competency requirements

2004

 

initiated

 

nationwide

 

pilot

 

demonstrations

Funded in part by AHRQ

The

 

CNL is

 

theorized

 

to

 

provide

 

clinical

 

leadership

 

at

 

the

 

point

of

practice

 

to

 

promote

 

and

 

sustain

 

cross

disciplinary

 

collaborative

 

practice

 

and

 

improve

 

care

 

(4)

Clinical Nurse Leader Evidence

Evidence

 

of

 

effectiveness

  

Positive

:

 

Consistent

 

improvement

 

in

 

quality

 

care

 

standards

 

and

 

patient

 

safety

 

outcomes

 

wherever

 

the

 

CNL

 

has

 

been

 

implemented

 

and

 

documented

Negative:

 

weak

 

evidence

 

base,

 

consisting

 

primarily

 

of

 

case

 

study

 

design

 

or

 

single

 

microsystem

 

analyses

An

 

important

 

finding

 

across

 

reports

 

was

 

that

 

the

 

CNL

 

is

 

not

 

yet

 

clearly

 

defined

 

in

 

terms

 

of

 

fundamental

 

leadership

 

activities

 

and

 

responsibilities

 

necessary

 

to

 

facilitate

 

outcomes

This

 

lack

 

of

 

practice

 

clarity

 

limits

 

the

 

ability

 

to

 

articulate,

 

(5)

Objective and Methods

The

 

purpose

 

of

 

this

 

research

 

was

 

to

 

clarify

 

CNL

 

practice

 

components

 

contributing

 

to

 

improved

 

quality

 

care

 

standards

 

and

 

patient

 

safety

 

outcomes

Interpretive

 

synthesis

 

design

 

was

 

used

 

to

 

integrate

 

diverse

 

CNL

 

practice

 

narratives

 

(research

 

reports,

 

articles,

 

webinars,

 

conference

 

abstracts,

 

etc.)

 

into

 

a

 

coherent

 

understanding

 

of

 

CNL

 

practice

Grounded

 

theory

 

analytical

 

approach

 

was

 

used

 

to

 

empirically

 

derive

 

a

 

CNL

 

Practice

 

Model

 

that

 

clarifies

 

(6)

Report Category Description of Category Total Count

Included in Synthesis

CNL practice reports and narratives

Documents including journal articles, webinars, job analyses, case studies and implementation reports that describe some aspect of CNL implementation and practice

30 Yes Qualitative/mixed methods

study

Studies describing the experience of practicing CNLs using qualitative methods, including investigator-designed survey data used for descriptive and qualitative analysis

8 Yes Quantitative study Descriptive, survey or quasi-experimental studies

examining the CNL role using inferential statistical analysis to quantify results

3 Yes Explanatory/editorial Documents describing the vision, history, rationale,

educational competency development, and/or editorial commentary about the CNL, but do not provide information on the role in action

38 No Journalism Short, informative briefs introducing or commenting on

the role in general but do not provide information on the role in action

43 No

Not about CNL role Reports that were not actually about the CNL 16 No

Total 138 41 Conference Abstract Category

QI (quality improvement) CNL-initiated QI project 122 Yes

Implementation/outcomes Describes the need for and implementation of CNL(s),

sometimes with outcomes 54 Yes

Educational methods Describes methods to educate/train CNLs, including developing partnerships with clinical organizations and placing CNLs into practice

39 Yes Immersion methods Describes clinical immersion experience of CNL students,

including how they were operationalized into the organizational setting

20 Yes

How CNL can be utilized Describes how and why CNL can be utilized 9 Yes

CNL experience Description/analysis of CNL personal experience 7 Yes

Quantitative/survey study Cross-sectional survey method investigating some aspect

of CNL practice 3 Yes

(7)
(8)

Data Saturation

CNL Practice Domain

Percent of reports/abstracts domain codes found in

Preparation for CNL practice

79%

Structure of CNL practice

79%

Continuous Leadership

93%

Outcomes of CNL practice

86%

(9)

CNL = Continuous Leadership

The

 

heart

 

of

 

CNL

 

practice

 

involves

 

developing

 

relationships

 

across

 

professions

 

to

 

promote

 

and

 

manage

 

information

 

exchange,

 

shared

 

decision

making,

 

and

 

effective

 

care

 

processes

 

at

 

the

 

point

of

practice

Components

 

of

 

continuous

 

leadership

 

include:

Being

 

a

 

source

 

of

 

constant

 

communication/information

Strengthening

 

inter

professional

 

relationships

Team

 

creation

Supporting

 

staff

 

engagement

Shifting

 

focus

 

from

 

person

 

to

 

process

All

 

components

 

have

 

evidence

 

supporting

 

effectiveness

The

 

innovation

 

is

 

workflow

 

responsibility

 

for

 

continuous

leadership

May

 

be

 

more

 

effective

 

than

 

episodic

 

training,

 

especially

 

in

 

organizations

 

with

 

less

 

leadership

 

across

 

levels

(10)

CNL Practice Model

How

 

does

 

the

 

model

 

align

 

with

 

current

 

theories

 

of

 

healthcare

 

delivery

 

and

 

improvement?

How

 

do

 

these

 

domains

 

interact

 

to

 

produce

 

successful

 

(11)

CNL Practice: Multi‐Level Intervention

Healthcare

 

System

 

Level

Assumed

 

Drivers

 

of

 

Change

Approaches

 

to

 

Change

CNL

 

Practice

 

Model

 

Larger

 

system,

 

Policy

 

Environment

Reimbursement

regulatory

 

policy

Accreditation

Public

 

reporting

Evidence

 

based

 

practice

Preparation for

 

CNL

 

Practice

Need

 

for

 

reporting

 

outcome

 

improvement

Structure

 

of

 

CNL

 

Practice

Care

 

structure

 

redesign

Outcomes

based

Competency

 

driven

Out

come

 

of

 

CNL

 

Pr

actice

B

ette

r

 

wo

rk

 

en

vir

o

nmen

t,

 

ca

re

 

qualit

y,

 

nur

sing

 

visibility

Organization

Structure

Strategy

Continuous Quality

 

Improvement

Organization

 

structure

 

development

Knowledge

 

management

Group

Cooperation

Coordination

Shared

knowledge

Team

 

development

Task

 

redesign

Guideline,

 

protocol,

 

pathway

 

implementation

Continuous

 

Leadership

Communication

Relationship building

Team

 

creation

Staff

 

engagement

Person to

 

process

Acceptance

Exposure,

 

feedback

Individual

Knowledge

Skills

 

Expertise

Education

Feedback

Leadership

 

development

(12)

context

Implementation

 

process

theory

Patient

 

safety

 

practice

Patient

 

safety

 

problem

Beneficial

 

safety

 

outcomes

AHRQ: Patient Safety Model

Moderators

 

of

 

patient

 

safety

 

practices

A

 Patient Safety Practice (PSP) is a type of process or structure whose 

application reduces the probability of adverse events 

Complex interventions targeting varying system levels

(13)

Context

Implementation

 

process

Theory

Patient

 

safety

 

problem

Preparation

 

for

CNL

 

practice

Structure

CNL

 

practice

 

of

 

Acceptance

CNL Practice = Patient Safety Practice?

CNL

 

Practice:

 

Continuous

 

Leadership

Outcomes

Moderators

 

of

 

patient

 

safety

 

practices

Communication

Interdisciplinary

 

relationships

Teamwork

Staff

 

support

Shift

 

focus

 

from

 

person

 

to

 

process

5

  

for

 

the

 

price

 

of

 

1

(14)

Conclusions

The empirically derived CNL practice model 

proposes five domains that interact to produce the 

structure, function, and outcomes of CNL practice

Clarifies

 

CNL

 

practice

 

components

 

Differentiates

 

them

 

from

 

existing

 

nursing

 

roles

Proposes

 

mechanisms

 

by

 

which

 

a

 

CNL

integrated

 

care

 

delivery

 

system

 

can

 

improve

 

healthcare

 

quality

The model can be helpful to organizations 

contemplating CNL implementation

Care

 

delivery

 

redesign

 

as

 

patient

 

safety

 

practice

(15)

Implications

The synthesis highlights CNL practice as a nurse‐

led intervention that can promote and sustain 

healthy interdisciplinary care environments 

Consistent

 

with

 

the

 

IOM

 

Initiative

 

on

 

the

 

Future

 

of

 

Nursing

 

Strategic

 

Plan

 

to

 

capitalize

 

on

 

the

 

contributions

 

of

 

nurses

 

to

 

quality

 

care

 

and

 

the

 

benefits

 

of

 

nurse

led

 

models

 

of

 

care

 

for

 

improving

 

healthcare

 

delivery

Provides a solid basis for future research

Confirm

 

domains

 

across

 

a

 

wider

 

sample

 

of

 

microsystems

Valid

 

measures

 

of

 

CNL

 

practice

 

domains

Further

 

investigation

 

into

 

microsystem

 

clinical

 

leadership

How do perceptions of collaborative practice form in differing 

disciplines and how do they come to be shared

(16)

Thank You!

Questions?

References

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