Miriam
Bender,
PhD
RN
Developing
a
Clinical
Nurse
Leader
Practice
Model
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
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
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,
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
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
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%
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
CNL Practice Model
How
does
the
model
align
with
current
theories
of
healthcare
delivery
and
improvement?
How
do
these
domains
interact
to
produce
successful
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
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
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
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
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
Thank You!
Questions?