Clinical Nurse Leadership in Clinical Nurse Leadership in the Critical Care Settingthe Critical Care Setting

Karen S. Broderick, MSN, RN, CCRNKaren S. Broderick, MSN, RN, CCRN

Clinical Nurse Leader for Critical CareClinical Nurse Leader for Critical Care

Middlesex HospitalMiddlesex Hospital

January 2014 January 2014

ObjectivesObjectives

Define the role of the CNLDefine the role of the CNL Discuss current CNL initiativesDiscuss current CNL initiatives Understand the relationship to patient safety and Understand the relationship to patient safety and

quality improvementquality improvement Where are we now? Where are we now?

Question asked in 2003Question asked in 2003

What does the nursing profession need What does the nursing profession need to be able to do to meet the needs of to be able to do to meet the needs of

the current and future healthcare the current and future healthcare system?? system??

The AnswerThe Answer

A Clinical Nurse Leader:A Clinical Nurse Leader: This nursing role function as a Masters-This nursing role function as a Masters-

prepared generalist providing and prepared generalist providing and managing care at the point of care to managing care at the point of care to

patients, individuals, and patients, individuals, and families…….along with the authority, families…….along with the authority,

autonomy and initiative to design autonomy and initiative to design and implement care, the CNL is and implement care, the CNL is

accountable for improving individual accountable for improving individual care outcomes and care processes in care outcomes and care processes in

a quality, cost-effective manner.a quality, cost-effective manner.

CNL roleCNL role AACN- February 2007: AACN- February 2007: White Paper on the White Paper on the

Education and Role of the Clinical Nurse Education and Role of the Clinical Nurse LeaderLeader

There is a documented need for the CNL There is a documented need for the CNL role in assuring quality and cost role in assuring quality and cost effectiveness of nursing careeffectiveness of nursing care

Education: Master’s prepared – generalistEducation: Master’s prepared – generalist– Not specific like a CNS or APRNNot specific like a CNS or APRN– Does not have prescriptive authority Does not have prescriptive authority

What does a CNL do? What does a CNL do?

Depends on the settingDepends on the setting Patient populationPatient population Staff resourcesStaff resources The role continues to evolve through The role continues to evolve through

education and practice but the education and practice but the emphasis is on patient safety, QI, emphasis is on patient safety, QI, lateral integration of care, lateral integration of care, interprofessional communication and interprofessional communication and EBP implementationEBP implementation

The CNL is: The CNL is:

Leader in decisions for clinical interventionsLeader in decisions for clinical interventions Works at the point of care and is primarily unit Works at the point of care and is primarily unit

based and ideally in conjunction with a DNPbased and ideally in conjunction with a DNP A professional within an interdisciplinary care A professional within an interdisciplinary care

environment- peers and collaborators with environment- peers and collaborators with knowledge and skill for negotiated care knowledge and skill for negotiated care expectations (i.e. recommendations for care)expectations (i.e. recommendations for care)

2 year implementation period minimum2 year implementation period minimum

Lateral integration of care for a specified group of Lateral integration of care for a specified group of patientspatients

-Intubated/ Sepsis patients Clinician Clinician

– may actively provide direct patient care in complex situationsmay actively provide direct patient care in complex situations– emphasis on health promotions and risk reductionemphasis on health promotions and risk reduction

Outcomes managerOutcomes manager– Responsibility for the ongoing assessment of the plan of care.Responsibility for the ongoing assessment of the plan of care.– Has the decision-making authority to change care plans if Has the decision-making authority to change care plans if

necessarynecessary– Accountability for evaluation and improvement in point-of-Accountability for evaluation and improvement in point-of-

care outcomescare outcomes

A major component of the CNL role A major component of the CNL role centers on fostering and sustaining a centers on fostering and sustaining a culture of safety for the patients and culture of safety for the patients and families entrusted into their care families entrusted into their care (Reid & Dennison, 2011) (Reid & Dennison, 2011)

The CNL is not: The CNL is not:

A direct care RN or charge RNA direct care RN or charge RN An administrator or managerAn administrator or manager A Nursing Supervisor or Case A Nursing Supervisor or Case

ManagerManager An APRN/NP/Clinical Nurse Specialist An APRN/NP/Clinical Nurse Specialist

CNL Evidence-Based OutcomesCNL Evidence-Based Outcomes

Evidence reported in the literature continues to Evidence reported in the literature continues to grow:grow:

– Improved patient, MD and RN satisfaction Improved patient, MD and RN satisfaction

scoresscores– Improved NDNQI scoresImproved NDNQI scores– Improved core measures, decreasing HAIs, Improved core measures, decreasing HAIs,

falls, restraint usage, etc. falls, restraint usage, etc. – Improved coordination of care and decreased Improved coordination of care and decreased

fragmentation of care esp with nursing handoff fragmentation of care esp with nursing handoff reports reports

– Decreased LOS Decreased LOS

So where are we So where are we now? now?

Patient SafetyPatient Safety

Quality ImprovementQuality Improvement

Handoff Communication Handoff Communication

CCU Fall Prevention

02

468

1012

Q42011

Q12012

Q22012

Q32012

Q42012

Q12013

Q22013

Q32013

Q4 2013

Time

Pat

ien

t F

alls

CCU

CNL Role Initiated

% of BGMs < 180 mg/dl in CCU Intubated/Septic patients

May 2012 – Oct 2013 CNL role

initiated

BGM focus

CCU Daily Goals CCU Daily Goals

To be revised to better fit our quality To be revised to better fit our quality and safety indicatorsand safety indicators

Night staff fills out part of the goals Night staff fills out part of the goals sheet sheet

Followed up by the day staff and Followed up by the day staff and presented during rounds reportpresented during rounds report– MDs follow the format as well to make sure MDs follow the format as well to make sure

components are addressed and not missed components are addressed and not missed CNL and Intensivist collaborate on

patients daily and PRN

Thank you !Thank you !

ReferencesReferences AACN (2007). White Paper on the Education and Role of the AACN (2007). White Paper on the Education and Role of the

Clinical Nurse Leader. Retrieved from Clinical Nurse Leader. Retrieved from http://www.aacn.nche.edu/Publications/WhitePapers/ClinicalNurseLeader07.pdf

Broderick, Karen Schilling (2013). A portrait at the bedside: Broderick, Karen Schilling (2013). A portrait at the bedside: clinical nurse leaders complete the picture. clinical nurse leaders complete the picture. Nursing Nursing ManagementManagement, 44(11), 10-11. , 44(11), 10-11.

Poulin-TaboPoulin-Taborr, D., Quirk, R.L., Wilson, L, Orff, S., Gallant, P., , D., Quirk, R.L., Wilson, L, Orff, S., Gallant, P., Swan, N., & Manchester, N. (2008). Pioneering a new role: Swan, N., & Manchester, N. (2008). Pioneering a new role: the beginning, current practice and future of the Clinical Nurse the beginning, current practice and future of the Clinical Nurse

Leader. Leader. Journal of Nursing ManagementJournal of Nursing Management, 16, 623-628., 16, 623-628. Reid,. K., Dennison, P., (September 30, 2011) "The Clinical Nurse Reid,. K., Dennison, P., (September 30, 2011) "The Clinical Nurse

Leader (CNL)®: Point-of-Care Safety Clinician" Leader (CNL)®: Point-of-Care Safety Clinician" OJIN: The Online OJIN: The Online Journal of Issues in NursingJournal of Issues in Nursing Vol. 16, No. 3, Manuscript 4. Vol. 16, No. 3, Manuscript 4.