implementing the clinical nurse leader role in a for...

JONAVolume 38, Number 6, pp 302-307Copyright B 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

Implementing the Clinical Nurse LeaderRole in a For-Profit EnvironmentA Case Study

Jesse Gabuat, MSN, RN

Nancy Hilton, MN, RN

Leah S. Kinnaird, EdD, RN

Rose O. Sherman, EdD, RN, CNAA, BC

The Clinical Nurse Leader project marks the firsttime in 35 years that nursing has introduced a newrole to the profession. The project has evolved toinclude partnerships between more than 90 univer-sities and 190 clinical sites. The authors present acase study of how a for-profit medical center createda sense of urgency for change, built a business case,and redesigned professional nursing practice to im-plement the Clinical Nurse Leader role.

In 2004, the American Association of Colleges ofNursing (AACN) convened stakeholders to discusswhat changes were needed in nursing education forthe future to address the growing body of knowl-edge about the need for improvements in health-care. Participating nursing leaders were urged tothink completely out of the box as they looked atthe issues and challenges of today’s healthcare de-livery system. Their discussions led to the design ofthe Clinical Nurse Leader (CNL) role and the ini-tiation of the CNL pilot project.1

American Association of Colleges of Nursing’srequest for proposals had a unique requirement.Universities and colleges interested in offering theCNL curriculum had to engage a healthcare servicepartner that was committed to redesigning nursing

care delivery to incorporate the new CNL role.2 Withmore than 90 universities and 190 clinical partner-ship sites,3 many service partners have found im-plementing a new nursing role and redesigning aprofessional nursing practice challenging. Rogers,4 inhis work on the diffusion of innovation, noted thatimplementing an innovation is a difficult processeven when a new idea may have obvious advantages.The purpose of this article was to provide a casestudy of those challenges and the process used by onemedical center to create a sense of urgency forchange, build a business case, and redesign pro-fessional nursing practice. An unusual feature of thiscase study is that the service partner, St Lucie Medi-cal Center (SLMC), is part of a for-profit hospitalcorporation, one of few for-profit corporations in-volved in the nationwide CNL project.

The CNL Role

Like many colleges of nursing that received the re-quest for proposals from AACN in 2004, the fac-ulty of the Christine E. Lynn College of Nursingat Florida Atlantic University (FAU) was intriguedand recognized the need to assess interest frompotential service partners. Chief nursing officers(CNOs) in the community told us that the practicechallenges described in the CNL white paper1 wereconsistent with their experiences (Figure 1). Theyalso told us that the role competencies for theCNL (Figure 2) were skill sets that were criticallyneeded for registered nurses (RNs) to be leaders atthe point of care.5 The congruence between whatthe academic setting could offer in terms ofcurriculum and their need for improvements in

302 JONA � Vol. 38, No. 6 � June 2008

Authors’ Affiliations: Nursing Director (Mr Gabuat); ChiefNursing Officer (Ms Hilton), St Lucie Medical Center, Port StLucie, Florida; Consultant (Dr Kinnaird), Creative Health CareManagement, Minneapolis, Minnesota; Director, Nursing Lead-ership Institute, and Robert Wood Johnson Executive NurseFellow (Dr Sherman), Christine E. Lynn College of Nursing,Florida Atlantic University, Boca Raton.

Corresponding author: Dr Sherman, Christine E. Lynn Collegeof Nursing, Florida Atlantic University, 777 Glades Rd, PO Box3091, Boca Raton, FL 33431 ([email protected]).

Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

practice prompted 6 service partners to participatein the pilot project.

Florida Atlantic University created a traditionalmaster’s degree program to support the developmentof the CNL role competencies using the AACN cur-riculum framework.6 Discussions with the servicepartners confirmed that graduates would need tobe able to demonstrate how their new role addsvalue to the provision of care. The service partnerswanted to offer their best and brightest nurses anopportunity to become CNL candidates. Key areasof concern from the partner’s perspective were help-ing graduates to understand the complexity of thehealthcare delivery system, financial reimbursement,and evidence-based practice. Communication, con-flict management, delegation, and team collabora-tion were felt to be essential leadership skills. Thedevelopment of the academic curriculum progressedquickly, and the first class started the program in fallof 2005.

Designing the curriculum was not as challengingas planning for the incorporation of a new role intothe practice setting. Work patterns can be rigid, andthe introduction of coworkers with new skill sets canbe threatening. As functions change, so must theform or model for the delivery of care. Redesigning

nursing care delivery is at the core of the CNL pilotproject. In her role as a CNL project consultant toAACN , Tornabeni7 has noted that the context ofhow nurses practice has changed, and the work ofnursing needs to be realigned to reflect this. As oneCNO in the partnership commented, if redesigningnursing care delivery was easy, we would havealready done it. St Lucie Medical Center enthusias-tically embraced this challenge. This is their story.

The CNL Role: A Case Study

St Lucie Medical Center, an affiliate of the HospitalCorporation of America, is a 194-bed for-profitorganization located on the Treasure Coast ofFlorida. The facility has been challenged in recentyears by both rising patient acuity and an influx ofnew residents, creating increased demand forhealthcare service. Moreover, the progressive cam-paign by regulatory agencies for standardized metricsto promote patient safety (such as core measures) andthe fundamental change from Bfee for service[ topay for performance have created an environmentrequiring a change in SLMC’s Bbusiness as usual[approach. The CNO recognized these changes,saw the CNL project as a unique opportunity, and

Figure 1. Practice challenges creating a need for clinical nurse leader’s role.

Figure 2. American Association of Colleges of Nursing end of program competencies for the clinical nurse leader’s role.

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seized the moment in SLMC’s history to strengthennursing practice.

Building the Business Case

In the spring of 2005, the CNO presented informa-tion to the senior executive team about the impactof core measures, pay for performance initiatives,shortened lengths of stay, and the growing concernof the nursing shortage on patient care. She pro-posed the CNL role and SLMC’s participation inthe pilot project as a solution to current problemsand future challenges. She advocated that an im-provement in care coordination, patient safety, andstaff engagement depended on strong nursing lead-ership at the point of care. Knowing the economicclimate, she proposed that the project would needto be full-time equivalent (FTE)Yneutral within thedivision of nursing. In addition, she proposed thatthere would be an improvement in staff reten-tion, decreased complications, and enhancement innursing documentation to meet reimbursement re-quirements. Based on SLMC’s vision, which includesemployee engagement, customer loyalty, quality care,and cost effectiveness, the following initial quantita-tive indicators were chosen: (a) staff retention, (b)physician and patient satisfaction, and (c) core mea-sures improvement. Because of the focus on out-comes, the administrative team approved a pilot forthe CNL project.

Planning Phase

With guidance from information presented duringthe CNL partnership meetings, SLMC’s nursing lead-ership met in the spring of 2005 to discuss poten-tial CNL candidates and selection strategy. After arigorous interview process, 4 SLMC baccalaureate-prepared RNs were selected to begin a nursing grad-uate program to prepare them for the CNL role. The4 CNL candidates came from various nursing back-grounds, ranging from bedside nursing to patientcare coordinator (PCC) role. They had diverse expe-rience, proven success in their previous roles, andhigh interest in this project. The 4 candidates were

approved by the CNO, met the criteria for admissionto the CNL graduate program, and were subsequentlysponsored by SLMC to receive a full scholarship.

With the assistance of grant funding from2 agencies, a consultant from Creative HealthcareManagement was engaged by FAU to help SLMClay the foundation for a new professional nursingcare delivery model that would incorporate theCNL role. Meetings were held with a focus groupcomprised of nursing leaders, PCCs, CNL students,and staff nurses. By the end of 3 sessions of opendialogue, the group had successfully accomplishedthe following:

� established the nursing philosophy and prin-ciples to guide the project,

� identified differences in the PCC and CNLroles,

� drafted the CNL job description (Figure 3),and

� framed the new nursing care delivery modelfor the pilot units.

With the support of the CNL students and theFAU faculty, the management team decided to moveforward with the project and allow the CNL studentsto pilot the role even before completing the curriculum.

The pilot units were a 36-bed progressive careunit and a 45-bed general medical/surgical unit.These units were selected because of the volume ofpatient admissions, transfers, and discharges; grow-ing number of new graduate nurses; increasingpatient acuity; inconsistent patient satisfaction scores;and number of patients with a diagnosis of congestiveheart failure and pneumonia who required coremeasure monitoring. Both units had strong leadershipsupport, which proved to be pivotal to the success ofthe project. The size of the units also allowed greaterflexibility in managing nursing hours and redesign-ing the nursing care delivery model.

With the pilot units identified, the nursingleadership met with the CNL students to discussthe logistics of how the project would be imple-mented. As plans evolved, they were also discussed

Figure 3. Key aspects of the St Lucie Medical Center clinical nurse leader’s job description.

304 JONA � Vol. 38, No. 6 � June 2008


at the CNL partnership meetings. A time line wasdeveloped (Figure 4), and methods to communicatewith staff and physicians were established. Theproposed CNL job description was reviewed withthe CNL students for their final input, and theoutcome measures were designated. Change, asCopnell and Bruni8 have observed, especially innursing practice, is thought to be a rational processbut difficult to achieve; therefore, staff engage-ment, commitment, and ownership of the projecthad to be gained to ensure success.

Discussions about the CNL role and proposedrevisions to the delivery model were conducted atstaff meetings before the implementation of theproject. This process was essential to create anavenue for the staff to raise questions and nursingleaders to clarify misconceptions and establish roledifferentiation. One of the most important elementsin the discussion was for nursing leaders to providereassurance that the role of each team member wascritical to the success of the project. These discus-sions continued through implementation of the role.To maintain the integrity of the CNL role, a sum-mary report from the focus group during the initialphase of the project was revisited, and role modi-fications were made as appropriate. The CNO andthe nursing leadership team recognized that theywould play a key role in maintaining the momentumof the project during the planning, implementation,and evaluation phases.

Implementation Phase

With guidance from Kotter’s9 change theory, thenursing leadership decided that the new nursing caredelivery model and CNL role would be implementedone unit at a time. The new nursing care deliverymodel was designed to address care fragmentation,

improve physician communication, provide supportto bedside nurses, and offer a consistent care leaderat the point of care, especially for high acuity andcore measure patients. In November 2006, the CNLproject was implemented in the progressive care unit.

Two CNL positions were introduced whilemaintaining the current bedside staffing model.Each CNL was assigned a patient load of 18, witheach CNL working closely with 3 staff nurses and2 patient care assistants. An hour-long weekly meet-ing was conducted by the department director toallow for an open discussion and assess the progressof the project based on staff personal experiences.

The most common concern raised by the staffinvolved role delineation. Role conflict and overlapbetween the CNLs and the PCCs were the focus ofdiscussion. The plan to begin the pilot with 1 unitproved extremely effective because the leadershipteam was able to focus on 1 unit and closely moni-tor the progress of the project. This was accom-plished by a daily dialogue between the leadershipteam and the CNLs and PCCs. Necessary modifi-cations were made to strengthen and value these2 roles. In an effort to maintain the integrity ofthe CNL role, the PCC’s responsibility was modi-fied to focus on the administrative aspect of unitmanagement, whereas the CNL role was focusedon the clinical outcomes and practice development.Furthermore, the PCC role was structured as a teamleader, overseeing the overall unit operation includ-ing staff scheduling and assignment, unit through-put, and coordination of unit-based activities. Havinga clear delineation between the 2 roles, the bedsidenurses gained expert resources on both clinical andadministrative aspects of patient care.

In December 2006, the new nursing care de-livery model with 2 CNL positions was introduced

Figure 4. Time line of the clinical nurse leader project at St Lucie Medical Center.

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to the second pilot unit, a general medical/surgicalunit. In keeping with the new delivery model, thebedside staffing standard was reinforced. A focusgroup comprised of CNLs, PCCs, staff nurses,and patient care assistants met regularly with thedepartment director to discuss the progress of theproject. Equipped with lessons learned from thefirst pilot input from the staff and improved clarityabout the CNL role, a better transition and accept-ance of the CNL role occurred.

To meet the goal of staying FTE-neutral whileimplementing the CNL project, each unit’s patientsupport structure was revamped. This was accom-plished by converting the unit secretary position toa CNL position. This strategy allowed the leader-ship team to incorporate advanced-studiesYpreparedand clinically competent nurses, which were funda-mental to achieving positive outcomes. In addition,an opportunity arose when a low-volume specialtyprogram was eliminated, allowing the CNO to movea vacated FTE to each pilot unit. Although the pro-ject was not budget-neutral, it met the target of re-maining FTE-neutral.

Evaluation Phase

In an outcome-driven environment, nursing leaderswere sensitive to the need to present data duringthe pilot phase to demonstrate how the new deliv-ery model was impacting care and other organiza-tional indicators. To evaluate the outcome of theproject, SLMC project leaders reviewed the chosenindicators and compared the preimplementationand postimplementation data. The core measureresults (congestive heart failure, acute myocardialinfarction, and pneumonia), physician and patientsatisfaction, and nursing turnover showed earlyimprovement, as indicated in Table 1.

The CNLs on the pilot units began the col-lection of qualitative data, such as the identifica-tion of near misses on their units and situationswherein physicians have opted not to transfer pa-tients to intensive care unit because of the presenceof the CNL on the unit. The facility joined theAACN evaluation project and is part of a replicationstudy to assess CNL role outcomes. As the CNL roleat SLMC continues to evolve, CNL-sensitive out-come measures are being identified and analyzed tocapture the true impact of the role not only in patientoutcomes and staff engagement but also in the over-all health of the organization.

Lessons Learned

During the process of transforming the nursingcare delivery model at SLMC, there were many lessonslearned. A critical factor in the success of the devel-opment and implementation of the CNL project atSLMC has been the commitment of the CNO. Thisstrategy rings true with the assertion of Redfern et al10

that the development of a culture to promote changesin nursing practice depends on strong leadership.Morijkian et al11 have noted from their research thatCNO support is a critical success factor to leadinginnovative changes in their organization. Maintain-ing the momentum of the project by having regularmeetings with the CNLs and the nursing staff wasimportant, as was maintaining close communicationwith the academic partner. Other key leadershipstrategies are outlined in Figure 5.

Table 1. PreYCNL and PostYCNLImplementation Outcomes, GeneralMedical/Surgery Department andProgressive Care Unit

Indicators4th Quarter

of 20064th Quarter

of 2007

Employee engagementNursing turnover

rateVNQF6.13% 3.20%

Customer loyaltyPatient satisfaction 3.40 3.46Physician satisfactiona 2.96 3.13

Quality care cost effectivelyCore measureVAMI 90% 97%Core measureVCHF 91% 96%Core measureVpneumonia 80% 85%

Abbreviations: AMI, acute myocardial infection; CHF,congestive heart failure; CNL, Clinical Nurse Leader; NQF,National Quality Form.aAnnual survey.

Figure 5. Key leadership success strategies.

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A major caveat to the introduction of theCNL role is the lack of empirical evidence becausethe role is brand new. It is not unusual for organi-zations to face challenges during each phase of theprocess; however, it is extremely important to learnvaluable lessons along the way and make necessaryadjustments until the proposed goals are achievedand objectives are met. Even so, as the healthcareenvironment evolves, so must our approach to meet-ing the demands of the communities we serve.

Conclusion

The case study of SLMC illustrates how nursingleadership can effectively establish a business caseand plan strategically to drive innovative practice

changes even in a for-profit environment. Althoughthe sustainability of early successes is not known,similar outcomes data from partners involved inthe AACN project have been very encourag-ing.12-14 As the CNL pilot project’s journey con-tinues, the ultimate success will depend on whatvalue the CNL role adds to patient care and to theorganizations that implement it.

Acknowledgments

The Florida Atlantic University Clinical NurseLeader project is supported by grant funding fromthe Health Resources and Services Administration,grant no. D65HP05366, and the Palm HealthcareFoundation of Palm Beach County, Florida.

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