Clinical Nurse Leader Practice Research Articles

Predictors of Clinical Nurse Leader implementation success across a national sample of settings: A Bayesian multilevel modeling analysis.

The Clinical Nurse Leader (CNL) care model is a different way of organizing frontline nursing care delivery in contrast to the traditional "staff nurse" model and is increasingly being adopted by health systems across the United States and abroad. However, variability in implementation and outcomes has been noted across health settings. A recently validated CNL Practice Model provides an explanatory pathway for CNL model integration into practice. The purpose of this study was to identify and compare patterns of empirical correspondence to the CNL Practice Model and predict their influence on implementation success. We conducted a secondary analysis of a 2015 national-level study with clinicians and administrators involved with CNL initiatives in their health system. A psychometrically validated CNL Practice Survey was used to collect data measuring the presence (0%-100%) of the five domains of the CNL Practice Model (organizational readiness, CNL structuring, CNL practices, outcomes, and value) and one measure of CNL implementation success. We modeled the complex hierarchical structure of the data using a Bayesian multilevel regression mixed modeling approach. A zero-one-inflated beta distribution, a mixture of Bernoulli distributions for the minimum and maximum responses and a beta distribution for the responses between the minimum and maximum, was used to fit success ratings in the model. A total of 920 participants responded, 540 (59%) provided success scores. The model captured ratings skewed toward upper bound, while also adequately modeling data between the minimum and maximum values. The Bayesian model converged and gave estimates for all hierarchical parameters, which would likely have failed to converge in a pure maximum likelihood framework. The variability around success score across CNL Practice Model element ratings was greatest at the component level, 0.29 (0.18-0.48), compared to either the domain level, 0.16 (0.01-0.54), or the item level, 0.09 (0.01-0.17). The components most predictive of implementation success were (a) consensus CNL model can close gaps, (b) organization level implementation strategy, and (c) alignment of empirical CNL microsystem level structuring to the model's conceptualization. Findings provide further empirical evidence to support the explanatory pathway proposed by the CNL Practice Model and identified specific organizational readiness and CNL workflow structures that are critical antecedents predictive of CNL practice manifestation and production of expected outcomes. Findings indicate actionable implementation evidence that can be successfully adopted across real-world healthcare settings to achieve safer and higher quality patient care. CNL integrated care delivery is a frontline nursing care model that is being increasingly adopted by health systems across the United States and abroad. However, variability in CNL implementation and outcomes has been noted across health settings, limiting its evidence base. Findings of this study contribute a better understanding about the variability of CNL practice and outcomes found in the literature and contribute empirical and conceptual clarity about the relationships between modes of CNL implementation and successful adoption in healthcare settings.

Factors Influencing Implementation Success of the Clinical Nurse Leader Care Delivery Model: Findings From a National-Level Mixed-Methods Study.

The clinical nurse leader (CNL) care model has existed since 2007. However, there is limited understanding how the model can best be implemented. A validated CNL Practice Survey measuring domains theorized to influence CNL implementation was used to examine the link between CNL domains and CNL implementation success. Mixed methods were used to analyze data from a nationwide 2015 survey administered to clinicians and administrators involved in CNL initiatives. Of total respondents (n = 920), 543 (59%) provided success scores, with 349 (38%) providing comments. Respondents with negative comments gave significantly lower average CNL success scores. The majority of negative comments mapped onto Readiness and Structuring domains, providing details of barriers to CNL implementation success. Findings provide information about structural domains that can be strategically targeted to better prepare settings for CNL implementation and success.

Using an Innovative Clinical Nurse Leader Practice Model to Sustain High-Quality Patient Care and Promote a Positive Work Environment During the COVID-19 Pandemic

The clinical nurse leader (CNL) provides clinical leadership at the point of care, offers staff mentorship, assumes accountability for clinical outcomes within the microsystem, and promotes evidence-based patient care. The CNL has the skills and competencies needed to facilitate improvement science and lead care delivery redesign in the ever-changing world of health care, including in times of crisis. This article aims to detail 1 pediatric medical center's journey in utilizing the CNL to sustain high-quality patient care and promote a positive work environment during the COVID-19 pandemic using an innovative, evidence-based CNL practice model.

Clarifying Role Expectations and Practice Standards Using a Clinical Nurse Leader Professional Practice Model Illustration.

Despite evidence of the positive impact of the clinical nurse leader (CNL) role, implementation of supplemental nursing roles has proven to be challenging due to unclear role explanations and organizational unfamiliarity. Nurses practice in a dynamic environment and need to cope with the rapid pace of change in practice roles. Outside of the preparation of the CNL, many nursing professionals are not educated or prepared on the essential aspects the CNL role. A graphic illustration was developed to facilitate discussion and provide insight into the CNL role, with the aim of creating consensus on the CNL role functions and expectations. Following the implementation of the CNL practice model illustration, participants reported a significant improvement in their understanding and importance of the CNL role. Professional practice model illustrations may be beneficial in developing a consensus of practice.

Advancing the clinical nurse leader model through academic-practice-policy partnership

The nursing profession is tasked with identifying and evaluating models of care with potential to add value to health care delivery. In consideration of this goal, we describe the Clinical Nurse Leader (CNL) initiative and the activities of a national-level CNL research collaborative. The CNL initiative, launched by the American Association of Colleges of Nursing in collaboration with education and healthcare leaders, has delineated CNL education curriculum and practice competencies, and fostered the creation of academic-practice-policy partnerships to pilot CNL integration into frontline nursing care delivery. The partnership has evolved into an Agency for Healthcare Research and Quality affiliate practice-based research network, the CNL Research Collaborative, which links research, policy, education, and practice stakeholders to advance the CNL evidence base. We summarize foundational CNLRC research to explain CNL practice, quantify CNL effectiveness, and bring clarity to how CNLs can be implemented to consistently influence care, quality, and safety.

Developing the Clinical Nurse Leader Survey Instrument: A Modified Delphi Study.

Clinical nurse leader (CNL)-integrated care delivery is an emerging nursing model, with growing adoption in diverse health systems. To generate a robust evidence base for this promising nursing model, it is necessary to measure CNL practice to explicitly link it to observed quality and safety outcome improvements. This study used a modified Delphi approach with an expert CNL panel to develop and test the face, content, and construct validity of the CNL Practice Survey instrument.

Organising nursing practice into care models that catalyse quality: A clinical nurse leader case study.

To determine the power of a conceptual clinical nurse leader practice model to explain the care model's enactment and trajectory in real world settings. How nursing, organised into specific models of care, functions as an organisational strategy for quality is not well specified. Clinical nurse leader integrated care delivery is one emerging model with growing adoption. A recently validated clinical nurse leader practice model conceptualizes the care model's characteristics and hypothesizes their mechanisms of action. Pattern matching case study design and mixed methods were used to determine how the care model's constructs were operationalized in one regional United States health system that integrated clinical nurse leaders into their care delivery system in 2010. The findings confirmed the empirical presence of all clinical nurse leader practice model constructs and provided a rich description of how the health system operationalized the constructs in practice. The findings support the hypothesized model pathway from Clinical Nurse Leader structuring to Clinical Nurse Leader practice and outcomes. The findings indicate analytic generalizability of the clinical nurse leader practice model. Nursing practice organised to focus on microsystem care processes can catalyse multidisciplinary engagement with, and consistent enactment of, quality practices. The model has great potential for transferability across diverse health systems.

Roles enacted by Clinical Nurse Leaders across the healthcare spectrum: A systematic literature review.

The Clinical Nurse Leader (CNL) is a master's prepared nurse envisioned to provide clinical leadership at the microsystem level to ensure safe, high quality patient-centered care. The American Association of Colleges of Nurses defined ten 'fundamental aspects' of CNL practice, but as the certified CNL population grows, data suggest they are filling a variety of positions besides formally designated CNL roles. This article reports the results of a systematic review of CNL literature to better understand what roles and activities certified CNLs are enacting when not hired into formally designated CNL roles. Sixty-nine articles met inclusion criteria. Roles identified include: faculty, 62%; clinical management/executive, 12%; specialty clinician, 11%; and staff nurse, 9%. In these roles, certified CNLs are reviewing literature, conducting research, and/or writing commentaries on CNL education and practice and other health foci such as alarm fatigue, insulin practices, and physical exercise for cancer-related fatigue. Results indicate that despite a lack of formal tracking of certified CNLs over time, the available information identifies a variety of roles and job titles used by this group of professional nurses. The study findings add to the body of knowledge informing overall understanding of the CNL initiative.

Organizing Nursing Knowledge And Practice Into Care Delivery Models That Catalyze Quality

Nurses represent the largest single component of hospital staffing, typically as a ratio to hospitalized patients. Observational studies have correlated higher nurse-patient ratios with better patient quality outcomes, yet the evidence has been summarized as too weak for policy or practice recommendations. Furthermore, examining nursing as a static entity doesn't provide necessary knowledge about ‘how’ nursing functions to influence quality, or how it can potentially be improved. Clinical Nurse Leader (CNL) integrated care delivery is an emerging nursing model with growing adoption in diverse health systems. A recent study empirically validated a CNL Practice Model that conceptualizes the care delivery’s Readiness, Structuring, Practice, Outcome, and Value domains. This study empirically characterized CNL-integrated care delivery mechanisms of action through analysis of the concrete operationalization of CNL Practice Model domains, using case study design. The case was a health system comprising four hospitals and a clinic network. The findings suggest nursing practice organized to focus on microsystem care processes catalyzes multidisciplinary engagement with, and consistent enactment of, best practices, through the ongoing activities of communication, relationship and team building, and engagement support. This occurs via a structured workflow that at first appears simply “wrong,” for example not having a patient assignment, but over time results in the care team knowing “what works in the clinical flow so quality is happening at the same time as practice.” The findings indicate the analytic generalizability of the model’s conceptual domains/pathways, and show how nursing can serve as an organizational strategy for continuous quality and improvement.

A Clinical Nurse Leader (CNL) practice development model to support integration of the CNL role into microsystem care delivery.

The Veterans Health Administration (VHA) Office of Nursing Services (ONS) was an early adopter of Clinical Nurse Leader (CNL) practice, generating some of the earliest pilot data of CNL practice effectiveness. In 2011 the VHA ONS CNL Implementation & Evaluation Service (CNL I&E) piloted a curriculum to facilitate CNL transition to effective practice at local VHA settings. In 2015, the CNL I&E and local VHA setting stakeholders collaborated to refine the program, based on lessons learned at the national and local level. The workgroup reviewed the literature to identify theoretical frameworks for CNL practice and practice development. The workgroup selected Benner et al.'s Novice-to-Expert model as the defining framework for CNL practice development, and Bender et al.'s CNL Practice Model as the defining framework for CNL practice integration. The selected frameworks were cross-walked against existing curriculum elements to identify and clarify additional practice development needs. The work generated key insights into: core stages of transition to effective practice; CNL progress and expectations for each stage; and organizational support structures necessary for CNL success at each stage. The refined CNL development model is a robust tool that can be applied to support consistent and effective integration of CNL practice into care delivery.

Refining and validating a conceptual model of Clinical Nurse Leader integrated care delivery.

To empirically validate a conceptual model of Clinical Nurse Leader integrated care delivery. There is limited evidence of frontline care delivery models that consistently achieve quality patient outcomes. Clinical Nurse Leader integrated care delivery is a promising nursing model with a growing record of success. However, theoretical clarity is necessary to generate causal evidence of effectiveness. Sequential mixed methods. A preliminary Clinical Nurse Leader practice model was refined and survey items developed to correspond with model domains, using focus groups and a Delphi process with a multi-professional expert panel. The survey was administered in 2015 to clinicians and administrators involved in Clinical Nurse Leader initiatives. Confirmatory factor analysis and structural equationmodelling were used to validate the measurement and model structure. Final sample n=518. The model incorporates 13 components organized into five conceptual domains: 'Readiness for Clinical Nurse Leader integrated care delivery'; 'Structuring Clinical Nurse Leader integrated care delivery'; 'Clinical Nurse Leader Practice: Continuous Clinical Leadership'; 'Outcomes of Clinical Nurse Leader integrated care delivery'; and 'Value'. Sample data had good fit with specified model and two-level measurement structure. All hypothesized pathways were significant, with strong coefficients suggesting good fit between theorized and observed path relationships. The validated model articulates an explanatory pathway of Clinical Nurse Leader integrated care delivery, including Clinical Nurse Leader practices that result in improved care dynamics and patient outcomes. The validated model provides a basis for testing in practice to generate evidence that can be deployed across the healthcare spectrum.

Promoting a Strategic Approach to Clinical Nurse Leader Practice Integration.

The Office of Nursing Services of the Department of Veterans Affairs (VA) piloted implementation of the clinical nurse leader (CNL) into the care delivery model and established a strategic goal in 2011 to implement the CNL role across the VA health care system. The VA Office of Nursing Services CNL Implementation and Evaluation (CNL I&E) Service was created as one mechanism to facilitate that goal in response to a need identified by facility nurse executives for consultative support for CNL practice integration. This article discusses strategies employed by the CNL I&E consultative team to help facility-level nursing leadership integrate CNLs into practice. Measures of success include steady growth in CNL practice capacity as well as positive feedback from nurse executives about the value of consultative engagement. Future steps to better integrate CNL practice into the VA include consolidation of lessons learned, collaboration to strengthen the evidence base for CNL practice, and further exploration of the transformational potential of CNL practice across the care continuum.

Variations in Clinical Nurse Leaders confidence with performing the core role functions

Background Clinical nurse leader (CNL) practice, by definition, requires individuals to make career transitions. CNLs must adjust to their new work role and responsibilities and doing so also entails individual adjustment. Prior work has not examined the role of individual-level factors in effective CNL role transition. This study contributes to CNL implementation efforts by developing understanding of personal and contextual factors that explain variation in individuals' levels of self-confidence with performing the key functions of the CNL role. Data were gathered using a cross-sectional survey from a national sample of registered nurses (RNs) certified as CNLs. Respondents' perceptions of their confidence in performing CNL role competencies were measured with the Clinical Nurse Leader Self-Efficacy Scale (CNLSES; Gilmartin MJ, Nokes, K. (in press). The Clinical Nurse Leader Self Efficacy Scale: Results of a pilot study. Nursing Economic$ ). The CNLSES is a 35-item state-specific self-efficacy scale with established measurement properties that assesses nurses' perceptions of their ability to function effectively as a CNL. Demographic data were also collected. Data were analyzed using a general linear regression model. One hundred forty-seven certified CNLs participated in the survey. Results indicate that respondents vary in their confidence with performing the nine role competencies associated with CNL practice. Results from regression analyses also show that respondents' confidence in their abilities to carry out the core functions associated with the CNL role varied significantly across geographic region, organizational type, and by CNL graduate program model. The results of this study show important differences in CNLs' levels of self-confidence with the core competencies of their role. As a result, it may be important to develop targeted career transition interventions to gain the full benefit of CNL practice.

Growing and Sustaining the Clinical Nurse Leader Initiative: Shifting the Focus From Pioneering Innovation to Evidence-Driven Integration Into Healthcare Delivery.

The Clinical Nurse Leader (CNL) initiative has been characterized by innovation. While an innovation framework for diffusing CNL practice remains relevant, generalizable evidence of effectiveness is necessary to sustain nationwide momentum. A framework is proposed in this department for a national-level CNL research collaborative linking research, policy, education, and practice stakeholders in an ongoing partnership to advance CNL evidence, education, policy, and practice.

Clinical Nurse Leader Integration Into Practice: Developing Theory To Guide Best Practice.

Numerous policy bodies have identified the clinical nurse leader (CNL) as an innovative new role for meeting higher health care quality standards. Although there is growing evidence of improved care environment and patient safety and quality outcomes after redesigning care delivery microsystems to integrate CNL practice, significant variation in CNL implementation has been noted across reports, making it difficult to causally link CNL practice to reported outcomes. This variability reflects the overall absence in the literature of a well-defined CNL theoretical framework to help guide standardized application in practice. To address this knowledge gap, an interpretive synthesis with a grounded theory analysis of CNL narratives was conducted to develop a theoretical model for CNL practice. The model clarifies CNL practice domains and proposes mechanisms by which CNL-integrated care delivery microsystems improve health care quality. The model highlights the need for a systematic approach to CNL implementation including a well-thought out strategy for care delivery redesign; a consistent, competency-based CNL workflow; and sustained macro-to-micro system leadership support. CNL practice can be considered an effective approach to organizing nursing care that maximizes the scope of nursing to influence the ways care is delivered by all professions within a clinical microsystem.

Conceptualizing clinical nurse leader practice: an interpretive synthesis.

The Institute of Medicine's Future of Nursing report identifies the clinical nurse leader as an innovative new role for meeting higher health-care quality standards. However, specific clinical nurse leader practices influencing documented quality outcomes remain unclear. Lack of practice clarity limits the ability to articulate, implement and measure clinical nurse leader-specific practice and quality outcomes. Interpretive synthesis design and grounded theory analysis were used to develop a theoretical understanding of clinical nurse leader practice that can facilitate systematic and replicable implementation across health-care settings. The core phenomenon of clinical nurse leader practice is continuous clinical leadership, which involves four fundamental activities: facilitating effective ongoing communication; strengthening intra and interprofessional relationships; building and sustaining teams; and supporting staff engagement. Clinical nurse leaders continuously communicate and develop relationships within and across professions to promote and sustain information exchange, engagement, teamwork and effective care processes at the microsystem level. Clinical nurse leader-integrated care delivery systems highlight the benefits of nurse-led models of care for transforming health-care quality. Managers can use this study's findings to frame an implementation strategy that addresses theoretical domains of clinical nurse leader practice to help ensure practice success.

Variations in clinical nurse leaders' confidence with performing the core role functions.

Clinical nurse leader (CNL) practice, by definition, requires individuals to make career transitions. CNLs must adjust to their new work role and responsibilities and doing so also entails individual adjustment. Prior work has not examined the role of individual-level factors in effective CNL role transition. This study contributes to CNL implementation efforts by developing understanding of personal and contextual factors that explain variation in individuals' levels of self-confidence with performing the key functions of the CNL role. Data were gathered using a cross-sectional survey from a national sample of registered nurses (RNs) certified as CNLs. Respondents' perceptions of their confidence in performing CNL role competencies were measured with the Clinical Nurse Leader Self-Efficacy Scale (CNLSES; Gilmartin MJ, Nokes, K. (in press). The Clinical Nurse Leader Self Efficacy Scale: Results of a pilot study. Nursing Economic$). The CNLSES is a 35-item state-specific self-efficacy scale with established measurement properties that assesses nurses' perceptions of their ability to function effectively as a CNL. Demographic data were also collected. Data were analyzed using a general linear regression model. One hundred forty-seven certified CNLs participated in the survey. Results indicate that respondents vary in their confidence with performing the nine role competencies associated with CNL practice. Results from regression analyses also show that respondents' confidence in their abilities to carry out the core functions associated with the CNL role varied significantly across geographic region, organizational type, and by CNL graduate program model. The results of this study show important differences in CNLs' levels of self-confidence with the core competencies of their role. As a result, it may be important to develop targeted career transition interventions to gain the full benefit of CNL practice.