the clinical nurse leader: addressing health-care

The Clinical Nurse Leader:Addressing Health-Care ChallengesThrough Partnerships and InnovationJames L. Harris, DSN, APRN-BC, MBA, CNL, FAAN; Joan Stanley, PhD, CRNP, FAAN; and Robert Rosseter, MBA

Evidence demonstrates that the American health-care system is failing to meet quality, safety, and efficiency mandates. Inresponse to the need to raise core standards, education and practice leaders have come together to create a new master's-degree nursing role—the clinical nurse leader (CNL®).These CNL academic and clinical partnerships are producing measur-able and sustainable practice outcomes that are positively affecting the quality, safety, and cost of care.The CNL initiativedemonstrates the power of collaboration and the need to re-envision traditional nursing roles to meet the constantly emerg-ing challenges of health care.

Regulatory requirements, advances in technology andscientific knowledge, workforce demographics, and con-sumer expectations cause constant change in health-care

delivery and nursing practice. A decade of evidence demonstratesthat the American health-care system is failing to deliver safe,efficient, and timely patient-centered care (American HospitalAssociation, 2002; Institute of Medicine, 1999, 2003; Vest &Gamm, 2009). To transform the health-care environment andre-envision roles and systems, we need visionary leadership.Besides fostering fresh thinking, leaders must balance innova-tion with risk management, facilitate and communicate change,and engage interprofessional stakeholders in processes that resultin efficient, quality, safe, and sustainable care delivery (Porter-O'Grady & Malloch, 2009).

The role of regulation is to ensure patient safety, but thisrole must be balanced with the needs for innovation and or-ganizational change. Dr. Peter Buerhaus from the Center forInterdisciplinary Health Workforce Studies at the Institute forMedicine and Public Health at Vanderbilt University MedicalCenter has accused oversight bodies of overregulating the health-care system and has asserted that the market can more effectivelycorrect problems that plague the system (Saver, 2010).

As organizations implement innovative activities to ad-dress health-care reform initiatives and mandated regulationsand to incentivize systems as novel sustainable enterprises, anopportunity exists for organizations and academic institutionsto align their efforts. Clinical and academic partnerships cre-ate transformational avenues that result in patient-centered,forward-thinking, outcomes-driven work. Regulators have anopportunity to support or join these partnerships and recognizethe importance of innovation and the growing role nurses mustplay in a changing health-care system.

The clinical nurse leader (CNL®), a new masters-degreenursing role and national initiative spearheaded by the AmericanAssociation of Colleges of Nursing (AACN), emerged from anational dialogue with regulatory, academic, and practice leaderson how to address the many challenges facing the health-caresystem (American Association of Colleges of Nursing [AACN],2007). These conversations lead to academic-practice partner-ships that are collectively reporting positive, measurable out-comes affecting the quality, safety, and cost of care. Thoughmany of the outcomes are organization-specific because of therelative newness of the initiative, opportunities for multisystemand longitudinal inquiry exist.

This article provides an overview of CNL education, prac-tice, and credentialing; issues related to nursing regulation; andexamples of practice-academic partnerships that address quality,safety, and efficiency reform mandates.

CNL: Partnership and VisionGlobal health-care dilemmas and growing technological infra-structures fuel the call for action, innovation, and revolutionarychange in today's health-care system. Health-care providers andadministrators face an aging population, a growing need forhealth promotion and chronic-illness management across thelifespan, widening health disparities, and the need to offer moreservices with less human and fiscal capital. Though advancingscience and meeting the needs of society require specialization,the urgency to prepare individuals to coordinate care and helppatients navigate the complex health-care environment cannotbe dismissed (AACN, 2007).

Health care needs unified approaches by educators andclinicians. The diversity and skill sets in academic and clini-

40 Journal of Nursing Regulation

cal environments create opportunities to compound availableresources, experiences, knowledge, and skills when making deci-sions about clinical education, curriculum, and innovations inpractice (McDaniel & Driebe, 2001). These collaborative part-nerships are strengthened by mutual goals—including commonpurposes, values, and beliefs—that encourage and engage di-verse stakeholders (Reinertsen, Gosfield, Rupp, & Whittington,2007). Success requires a continuous assessment of resources,strengths, and weaknesses. The CNL initiative is an example ofinnovation and partnership that addresses the volatile health-care environment.

Evolution of the CNL RoleIn 1999, the Institute of Medicine (IOM) released its landmarkreport. To Err is Human: Building a Safer Health System, which

challenged health-care systems to reorient their efforts to reducemedical errors and improve patient safety. In 2002, the AmericanHospital Association and the Joint Commission released similarreports, and the Robert Wood Johnson Eoundation (Kimball &O'Neil, 2002) called for developing new practice models andenhancing collaboration between education and practice. Then,in 2003, the IOM released its five core competencies all clini-cians must have to meet patients' needs in the 21st centuryhealth-care system.

Several studies have demonstrated that nurses with bac-calaureate or higher-level degrees produce better patient-careoutcomes. Specifically, these nurses reduce mortality and fail-ure-to-rescue rates (Aiken, Clarke, Cheung, Sloane, & Silber,2003; Aiken, Clarke, Sloane, Lake, & Cheney, 2008, Estabrooks,Midodzi, Cummings, Ricker, & Giovanetti, 2005, Freise, Lake,Aiken, Silber, & Sochalski, 2008; Tourangeau et al., 2007). Thus,health care needs not only more nurses but also skilled, compe-tent graduates who can effectively lead the care of patients withmore complex and critical needs.

To address the calls to rethink the provision of nursingcare and nursing education, the AACN, with leaders from theeducation, practice, and regulatory arenas, developed the CNL,the first new master's-prepared nursing role in more than 35years. Since the publication of the original description of theCNL, the numbers of CNL education programs, enroUees, andgraduates have increased steadily. (See Eigure 1.)

CNL and APRNEarly in the development of the CNL, the AACN asked leadersin nursing and clinical nurse specialist (CNS) practice and educa-tion to develop a statement comparing the CNL and CNS roles(Spross et al., 2004). This statement describes the similarities,differences, and complementarities of the two roles. As with allnursing roles, some knowledge and skills overlap. However, theCNS is an advanced practice registered nurse (APRN) and a

FIGURE 1

CNL Programs, Enrollments, and Graduates

In the fall of 2006, 440 students were enrolled in 28 clini-cal nurse leader (CNL) programs. By the fall of 2009, thenunnbers grew to 1,808 students In 83 programs, with 499graduates in the 2008-2009 academic year. As of the win-ter of 2010, the Connnnission on Nurse Certification hascertified more than 1,200 CNL graduates.

Enrollments 2005-2009 andGraduations of CNL students 2006-2010

1,800-1,600-1,400-1,200-1,000-

800-600-400-200-

0-

- • - Students-B-Graduates

Number ofprograms

ti2005-2006

44036

28

^^..^ED

2006-2007

89960

56

2007-2008

1,270265

70

^^M

2008-2009

1,650467

81

•

D

2009-2010

1,808499

83

Source: American Association of Colieges of Nursing. (2005-2010). Insti-tutionai database.

specialist with advanced knowledge and expertise in a specialtyarea of practice, such as gerontology, women's health, oncology,or cardiovascular health. The CNL is prepared with a focus oncare coordination, quality, and safety without an area of specialtypractice. The CNL is not an APRN nor an administrative ormanagerial role. The CNL practices primarily at the microsystemlevel of care in any type of health-care setting; the CNS primarilyfunctions at the mesosystem and macrosystem levels.

The CNL can identify situations requiring the expertiseof the CNS. Eor example, the CNL may ask the CNS to pro-vide consultation when a specialty area of concern arises, such aswhen a cardiovascular patient does not respond to nursing careor therapeutics as expected. The CNS focuses on issues across thesystem and supports the CNL's role in overseeing patient careand identifying gaps in staff expertise at the unit level.

Implementation of the CNL RoleThroughPartnershipsIn Eebruary 2004, the AACN invited schools and practice orga-nizations to join the national initiative to establish partnerships.In response, 79 schools and 136 practice organizations acceptedthe invitation. Today, more than 100 academic-practice part-nerships, including 116 schools of nursing and well over 200practice settings, exist. The practice sites are largely acute-caresettings but also include state health departments, school-based

Volume 2/Issue 2 July 2011 www.journalofnursingregulation.com 41

TABLE 1

CNL Employment Settings (/V = 1,255)

This table shows where the currently certified clinical nursespecialists (CNLs) work.

Acute-care inpatient 654

Cornmunity health, public health 39

Home health 17

School health, university health 69

Nursing honne, long-term care, sub-acute care 13

Hospice 2

Hospital outpatient 26

Outpatient 37

Physician practice 3

Nurse-managed practice 5

School of nursing 237

Other 153Source: Commission on Nurse Certification database, September 2010.

health clinics, home care, long-term care, emergency depart-ments, outpatient clinics, and rehabilitation facilities. The part-nerships exist in 38 states and Puerto Rico.

In the partnerships, academia with input from practicesettings provides a curriculum to prepare students for the CNLrole, and practice settings with input from academia redesigncare delivery, maximizing the CNL role. The success of CNLpartnerships hinges on academia and practice working togeth-er. Through these partnerships, stereotypes of and assumptionsabout each other have diminished, and the common goal of anew nursing role in the health-care system has advanced. Theenergy, enthusiasm, and innovation going on across the countryhave created a sense of excitement for nursing. The engagementof nurses at all levels—from the staff nurse to the chief nursingofficer—has been critical to the success of the CNL initiative.

CNL PracticeAs the CNL gains experience, his or her practice may includemore advanced skills and knowledge. However, initial CNLpreparation builds on entry-level nursing knowledge and skillsand encompasses eight broad areas:• Clinician• Outcomes manager• Client advocate• Educator• Information manager• Systems analyst/risk anticipator• Team manager• Member of a profession/lifelong learner (AACN, 2007)

The CNL is a clinical leader-manager serving as the "air-traffic controller" on a unit or at the point of care in a health-care

delivery system. CNL preparation focuses on quality improve-ment, interprofessional communication, care coordination, andcost-effective resource utilization. CNL practice varies dependingon the setting, but the CNLs knowledge and skills are applicableand beneficial in all settings that deliver health care. Table 1shows the practice settings of the currently certified CNLs.

The defining aspects of CNL practice include the follow-ing:• Leadership in the care of patients and families in and across

all settings• Implementation of evidence-based practice• Lateral integration of care for a specified group or cohort of

patients• Clinical decision making• Oversight of the design and implementation of care plans• Risk anticipation, specifically evaluating anticipated risks

to patient safety with the aim of quality improvement andprevention of medical errors

• Participation in identifying and monitoring care outcomes• Accountability for evaluation and improvement of point-of-

care outcomes• Client and community advocacy• Education for individuals, families, groups, and other health-

care providers• Information management, including using information sys-

tems and technology at the point of care, to improve health-care outcomes

• Delegation and oversight of care delivery and outcomes• Team leadership and collaboration with other health profes-

sional team members• Interprofessional communication• Leverage of human, environmental, and material resources• Design and provision of health-promotion and risk-reduction

services for diverse populationsThe AACN 2007 White Paper on the Education and Role of

the Clinical Nurse Leader provides in-depth descriptions of theseaspects of CNL practice.

CNL Education: Preparation for Today'sHealth-Care EnvironmentStakeholders engaged in extensive dialogue about the appropriateeducational level to prepare CNLs. Crosswalking the essentialcompetencies for entry-level professional nurses with those iden-tified for the CNL showed that the additional knowledge, skills,and experiences needed for this new role could not be obtained ina 4-year baccalaureate nursing program. Based on this evaluationand input from multiple stakeholders, the AACN board decidedthe educational preparation must be at the graduate level in amaster's- or post-master's-degree program.

The CNL curriculum must prepare the graduate with coreoutcome competencies expected of all master's nursing programs


TABLE 2

CNL Curriculum Models

Clinical Nurse Leader(CNL) Curriculum iVIodel

Model A

Model B

Model C

Model D

Model E

Description

Program is designed for BSN graduates.

Program is designed for BSN graduates, and it includes a post-BSN residencythat awards mastör's-degree credit towards the CNL master's degree.Also known as a second-degree or generic master's-degree program, this pro-gram is designed for those with a baccalaureate degree in another discipline.Also known as an RN-MSN program, this program is designed for associate-degree graduates.Program is for post-master's-degree certification.

Number ofPrograms*

75

14

30

15

8

* Source: American Association of Colleges of Nursing. (2010). CNL database.

as well as the additional competencies described in the AACNwhite paper (AACN, 2007). The white paper also lays out theframework and recommended elements of the curriculum anddelineates the clinical experiences required to attain the end-of-program competencies. The CNL student must complete 400to 500 clinical hours as part of the formal education program.The student must spend at least 300 to 400 of these hours inan immersion experience, practicing in the CNL role with adesignated preceptor and a faculty partner. The immersion pro-vides the student with the opportunity to gain an overview ofthe care-delivery system or organization, practice in the CNLrole, and integrate the new learning into his or her practice. Therecommended length of immersion is 10 to 15 weeks.

CNL Master's-Degree Curricular ModelsFive curricular models for graduate CNL education programshave emerged. Table 2 describes the models and provides thenumber of programs in each.

Second-Degree or Generic Master's-Degree Program

Thirty generic master's-degree CNL programs have been devel-oped around the country (AACN, 2010). One question aboutthese programs frequently comes up: Can graduates functionin the CNL role without previous work experience as a nurse?Similar questions were raised during the early development of thenurse practitioner (NP) role. Yet, experience shows that nursesentering an NP program immediately or soon after earning abaccalaureate degree in nursing do as well as or better than nurseswho have been out of school for any length of time. Moreover,generic master's-degree programs teaching entry-level competen-cies and competencies for APRNs and NPs successfully preparegraduates for NP practice (Rich, 2005). The same may be ex-pected of the generic master's-degree CNL program.

Graduates of the generic master's-degree program are pre-pared with the entry-level baccalaureate-degree nursing compe-

tencies and the master's-degree CNL competencies. On gradua-tion, they must take the NCLEX® and provide proof of registerednurse (RN) licensure to be certified as a CNL. Graduates maytake the CNL certification exam at the end of the academicprogram, but they will not be granted the credential until docu-mentation regarding RN licensure is received.

Several curricular designs for the generic master's-degreeprograms have emerged. Some prepare the student with theentry-level competencies initially and then add the master's-degree CNL competencies. Generally, with this curricular de-sign, the student practices as a staff nurse while completing themaster's-degree program. Other designs integrate course workand experiences throughout the program but culminate with theCNL clinical immersion.

Several transition models are being developed nationallyand locally to help graduates of these programs transition intopractice. One model allows the graduate to practice in a tradi-tional staff nurse role several days a week and practice in the CNLrole the rest of the week. This approach allows the CNL graduateto gain experience and confidence as a professional nurse and tointegrate the CNL role into practice, model the CNL role forother nurses and staff, and build relationships and expectationsfor the role in the system. This approach also allows the employerto gradually integrate the CNL into the care-delivery systemand more quickly reap the benefits of improved quality, safety,and cost outcomes, which are the primary focus of the CNL'seducation. This transition period must be individualized for theCNL; however, early experience shows that CNL graduates fullytransition into the role in 12 to 16 months.

As the U.S. Department of Veterans Affairs works toimplement the CNL in every facility by 2016, it is developinga residency model for CNL graduates, both the traditional post-BSN master's-degree graduates and the generic master's-degreegraduates. The residency will be outcomes-based, and the lengthand type of experiences will be individualized. The Department


of Veterans Affairs anticipates piloting it at several sites in thenear future.

Post-master's-degree CNL Certificate Program

The post-master's-degree CNL certificate program is designedfor those who hold a master's degree in nursing that preparedthem for a specific area of practice or an advanced nursing spe-cialty. Demand for this program comes from nurses who areworking in settings where the CNL is being implemented andwho want to become CNLs. Demand also comes from employ-ers eager to implement the CNL, using master's-degree nursescurrently practicing in the setting.

Post-master's-degree candidates must successfully com-plete the graduate didactic and clinical requirements of amaster's-degree CNL program through a certificate program.Candidates are expected to achieve the same outcome competen-cies as master's-degree CNL students. The content identified ascritical to CNL role preparation and post—master's-degree cer-tificate programs can be found on the AACN website at http://www.aacn.nche.edu/cnl/pdf/PostMastersStmnt.pdf.

CNL Regulation: Licensure andCertificationThe CNL is educated and licensed as a professional RN. If notalready licensed, a CNL graduate must obtain and maintain li-censure.

To use the title "clinical nurse leader" or the credentialCNL, a graduate of a CNL master's-degree or CNL post-master's-degree certificate program must be certified by the Commissionon Nurse Certification (CNC), an autonomous arm of AACN.In contrast to licensure, which validates a clinician's minimumlevel of competence, certification indicates that one has achieveda higher level of competence in a more focused area of practice.To be eligible for CNL certification, an RN must graduate from aCNL master's-degree or post-master's-degree certificate programthat is accredited by a nursing accrediting agency recognized bythe U.S. Department of Education and that prepares individualswith the competencies delineated in the AACN white paper.

Twelve schools piloted the CNL Certification Examination®from November 2006 to January 2007. The first regular admin-istration of the exam occurred in April and May 2007. Since then,over 1,200 CNLs have been certified. An elected CNC Board ofCommissioners oversees all certification activities and policies.Employers and others recognize that nurses holding the CNLcredential have met national education requirements and havesuccessfully completed a rigorous examination that tests requisiteknowledge and experiences. To protect the integrity of the CNLdesignation, the AACN has trademarked the CNL title and theCNL Certification Examination.

CNL Value, Impact, and SustainabilityAs the CNL role continues to evolve and be adopted by health-care organizations, the impact of CNLs will be many, measur-able outcomes. The CNL's value must be assessed by knowingstakeholder's interest and establishing CNL outcome measuresappropriate to the setting (Fitzgerald, 2004; Morris, 2010).Porter-O'Grady, Clark, and Wiggins (2010) stated that themeans formerly used by nurses to value their work are now onlypartially meaningful. Obtaining value requires a convergenceof principle, evidence, and efforts; the connection between theresources and the outcomes must be evident.

Morris (2010) identified an iterative process in which valuecan be determined using a series of questions. The questions canguide organizations considering the adoption of the CNL roleby helping determine the overall value for the organization, thedepartment, and the customer; the financial impact; and therisk of not adopting and using the role outlined in the AACNwhite paper. Answers to the questions may provide support forrole sustainment for years.

As patient needs continue to change and the health-caresystem evolves, the CNL is in a pivotal position to introduceevidence-based interventions that produce intended effects.These effects can be aligned with activities that meet core mea-sures, national patient safety goals, and best available practices.Popper (1945) and Campbell and Russo (1999) advocated theintroduction of small interventions that deal directly with spe-cific issues, can be practically tested and measured, and are fun-damentally the same in all disciplines.

Few care settings have nurses to focus primarily on clinical-care coordination that culminates in meeting intended goals.CNLs are educated to analyze meaningful data and trends anddrive improvement initiatives. They serve as coaches and mentorsto other staff members and facilitate communication among staflfmembers and patients. This focus is timely as organizations adoptthe medical home model and other patient-aligned frameworks.

A CNL's actions shift the nonaligned and siloed practice ofthe past to a convergence of networking and synchronized care.Examples of how CNL activities are leading improvements atpublic and private facilities are provided in Table 3. Sustainingthese actions requires continuous alignment of activities by edu-cators and clinicians, using the best available evidence. However,several factors can contribute to poor sustainability, such as inad-equate time for educating others about practice changes, limitedresources and leadership support, and absence of an evidence-based culture (Hagedorn et al., 2006; Stetler, 2003; Wallin,Profetto-McGrath, & Levers, 2005). Argote (1999) and Huber(1991) encourage care settings to learn from the basic tenets oforganizational learning theory (acquisition, interpretation, stor-age, data retrieval, and use of knowledge) to sustain interventionsand introduce a new practice role.

This new paradigm will require systematic, enduring plan-ning and action by all stakeholders to ensure changes and prac-


TABLE 3

CNL Activities and Outcomes

To discover and sustain effective solutions to gaps in care delivery, clinical nurse leaders (CNLs) document clinical activitiesand outcomes over time. Early adopters of the CNL role are credited with the significant outcomes below.

Activity

1. Bedside shift reports

2. Pressure-ulcer reduction

3. Pain management

4. Development and use of educational materials on medi-cation, diagnosis, and crisis management with patientsadmitted to an inpatient mental health unit

5. Admission assessment completion

Outcome

1. Time to describe patient and five factors, such as pain andpositioning, during bedside shift report reduced from 90 to30 minutes

2. Reduced from 2% to 1% for pressure ulcers below stage II

3. Enhanced management, documentation, patient satisfac-tion, and call-light use with placement of "pain boards" inpatients' rooms

4. Increased medication education from 0% to 83%, diagnosiseducation from 5% to 88%, and crisis management from5% to 57%

5. Increased from 81% to 91%

6. Education on recognizing respiratory decompensation of 6. Decreased codes and readmissions to critical-care units, in-creased patient and provider satisfaction, and fewer intu-bations

patients assigned to medical units

7 Handoff communication during disaster relief

8. Nursing hours per patient day

9. Elective surgery cancellations

10.Gl procedure cancellations

11. Sitter hours assigned to medical/surgical unit per nnonth

12.Ventilator-associated pneumonia

7 Improved communication during end-of-shift team huddlesregarding individuals receiving medical care at shelters

8. Increased from 6.09 to 6.74 and 3.76 to 4.07 nursing hoursper patient day (Ranges are for one medical and one surgi-cal unit.)

9. Reduced by 55%

10. Reduced from 30% to 14%

n. Reduced from 676 to 24 hours per month (over 1 year)

12.Reduced from 21.7% to 8.7%

Sources: Harris, J. L., & Roussel, L. (2010). Initiating and sustaining the clinicai nurse ieader. A practical Guide. Sudbury, iVIA: Jones & Bartlett. On, K. M..Haddock, K. S., Fox, S. E., Shinn, J. L., Walters. S. E., Hardin, J. W., et al. (2009).The ciinical nurse leader: impact on practice outcomes in the VeteransHeaith Administration. Nursing Economics, 27(6), 363-383.

tices are embedded in organizational reservoirs (Virani, Lemietix-

Charles, Davis, & Berta, 2009). The ongoing visibility of senior

managers and engagement of all clinicians are required if the

CNL journey and contributions are to be realized and sustained.

Regulators have an equally critical role in supporting and part-

nering with academia and practice to recognize the role nursing

can play in improving care outcomes and to implement the CNL

role within the health-care system.

ConclusionsToday's quality, safety, and efficiency mandates are challenging

the American health-care system. The creation and implemen-

tation of the CNL role is one response to the challenges. In

collaboration with interprofessional teams, CNLs can initiate

activities that morph into standardized practices to protect and

promote the health of citizens and communities. Regulators,

educators, and practice leaders must work together to champion

innovations such as the CNL and other evidence-based solutions

to bridging gaps in the current health-care system.

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James L. Harris, DSN, APRN-BC, MBA, CNL, FAAN, isthe Deputy Chief Nursing Officer at the Department of Vet-erans Affairs in Washington, DC. Joan Stanley, PhD,CRNP, FAAN, is Senior Director of Education Policy andRobert Rosseter, MBA, is Chief Communications Officerand Associate Executive Director at the American Associationof Colleges of Nursing in Washington, DC.


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