Clinical Nurse Leader An Emerging Advance Practice Role Introduction • The Clinical Nurse Leader (CNL) is a new specialization in Nursing • There is a documented need for the CNL role in assuring quality and cost effectiveness of nursing care • There are differences of opinion on education and classification Origin of the Clinical Nurse Leader (CNL) Role “….unless nursing is able to create a professional role that will attract the highest quality women and men into nursing, we will not be able to fulfill our covenant with the public. The Clinical Nurse Leader (CNL) addresses the call for change.” AACN (February 2007) White Paper on the Education and Role of the Clinical Nurse Leader Impetus for Change • In 1999 the AACN Board of Directors identified a number of primary concerns related to care delivery: – Declining enrollment in baccalaureate nursing programs – Lack of success in differentiating practice of RNs with different educational preparation – Exponentially increased knowledge base for nurses(e.g., genetics, pharmacology), along with increasingly complex delivery systems – Numerous landmark studies reporting lack of high- quality patient care Supporting Studies • IOM landmark report To Err is Human: Building a Safer Health System (2000) focused on increasingly high rate of medical errors • JCAHO Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis (2002) recommended proposals for providing financial incentives for health care organizations to invest in high quality nursing care Supporting Studies • RWJ’s Health Care’s Human Crisis: The American Nursing Shortage (2002) recommends “the reinvention of nursing education and work environments to address and appeal to the needs and values of a new generation of nurses”. • IOM Health Professions Education: A Bridge to Quality (2003): “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.” Development of the CNL • 2002 an AACN task force created focused on needed nurse competencies – Clinical leadership in all health care settings – Implementation of outcomes-based practice and Quality Improvement strategies – Ability of RNs to practice at their full scope of education and ability – The creation and management of “microsystems” of care that will be responsive to the health care needs of individuals and families. • May 2003: Draft white paper The Role of the Clinical Nurse Leader • February 2007: White Paper on the Education and Role of the Clinical Nurse Leader Development cont. “….perhaps creating a powerful financial return-on-investment model based on higher quality of care, shorter length of stay, and improved clinical outcomes will more than justify the cost of such a role” . (Drenkard, 2004) Role Competencies • “The CNL functions as a Masters-prepared generalist providing and managing care at the point of care to patients, individuals, families, and communities…….along with the authority, autonomy and initiative to design and implement care, the CNL is accountable for improving individual care outcomes and care processes in a quality, cost-effective manner.” Educational Competencies • Critical thinking • Communication • Assessment • Nursing technology and resource management • Health promotion, risk reduction, and disease prevention • Illness and Disease management • Information and Health Care technologies • Ethics • Human Diversity • Global Health Care • Health Care Systems and Policy • Provider/Manager/Coordinator of Care Fundamental Aspects of CNL “Lateral integration of care for a specified group of patients” • Clinician – may actively provide direct patient care in complex situations – emphasis on health promotions and risk reduction • Outcomes manager – Responsibility for the ongoing assessment of the plan of care. – Has the decision-making authority to change care plans if necessary – Accountability for evaluation and improvement in point- of-care outcomes Fundamental Aspects of CNL • Client and community advocate • Educator • Information manager • Systems analyst/risk anticipator • Team manager • Collaboration with other health professional team members • Member of a profession • Lifelong learner Real-World Example “I was educated to use research to define and solve practice problems, to look beyond the obvious outcomes and to work to discover the true essence of practice problems. Through research, I learned to define problems on the unit by analyzing decreased patient satisfaction scores, the nurse turnover rate, staff morale, and increasing stress levels. I worked within the practice environment and studied how problems were being solved daily and how the flowthrough the GI lab was affected by other variables within the unit itself I evaluated how happy staff were with the way problems were being addressed by management and how their work performance was affected by their overall satisfaction with their work environment.” Miller(2008) Educational Preparation • AACN holds the position that the CNL should be Master’s prepared. • CNL is an advanced generalist education. • 65 schools in the U.S. offer a CNL program. AACN Education Models for CNL • Model A: Master’s degree program for BSN graduates that includes a post-BSN residency that awards master’s credit. • Model B: Master’s program designed for ADN graduates (RN-MSN). Education Models cont. • Model C: Master’s Program designed for individuals with a baccalaureate degree in another discipline (second- degree program). • Model D: Master’s degree program designed for BSN graduates. • Model E: Post-master’s certificate program designed for individuals with a master’s degree in nursing in another area of study. CNL Certification • AACN requires that the nurse meet the following criteria – Registered Nurse licensure – Graduation from an accredited CNL master's or post- master’s program • CNL exam is web-based – Two-part process involving multiple choice and simulation questions CNL Variations Graduate Level CNL Role CNL Role Expectations Curriculum Functions Elements Nursing Leadership Advocate Keeps clients well informed Includes clients in care planning Advocates for the profession Works with interdisciplinary team Strives to achieve social justice within the microsystem Member of a Effects change in health care practice Profession Effects change in health outcomes Effects change in the profession Care Environment Management Team Manager Properly delegates and manages Uses team resources effectively Serves as leader/partner on interdisciplinary team Information Uses information systems/ technologies Manager Improves health care outcomes Systems Participates in system reviews Analyst/Risk Evaluates/anticipates client risks to improve patient safety Anticipator Clinical Outcomes Management Clinician Designs/coordinates/evaluates care Delivers care in a timely, cost effective manner Emphasizes health promotion/risk reduction Clinical Outcomes Management Outcomes Uses data to change practice and improve outcomes. Manager Achieves optimal client outcomes Clinical Outcomes Management Educator Uses teaching/learning principles/strategies Uses current information/ materials/techniques Facilitates clients learning, anticipating their health trajectory needs. Facilitates client care using evidence-based resources. Facilitates group & other health professions’ learning and professional development Is CNL by definition an advanced practice role? • Advance practice registered nurse (APRN) is not defined in Washington Nurse Practice Guide (WDOH, 2005) • The CNL is not prepared as an advanced registered nurse practitioner (ARNP) as the ARNP is currently defined (WDOH, 2005) • APRN is a generic, umbrella term that encompasses ARNPs, CNSs, nurse anesthetists and nurse midwives. (APRN-JDC, 2008) Does CNL function in advanced practice role? • The CNL is an advanced generalist, functions at the unit level, and isn’t a patient population expert in contrast with the specialized focus of the practice by CNS and ARNP. • CNS and ARNP is prepared in a specialty curriculum which includes those clinical and didactic learning experiences identified and defined by the specialty nursing organization for the particular area of advanced clinical practice. Is CNL educated for advanced practice role? • Educated at the master’s degree, the CNL is prepared with nursing competencies as outlined in the AACN (1998) Essentials of Baccalaureate Education for Professional Nursing Practice and additional competencies as outlined in the Working Paper on the Role of the Clinical Nurse Leader (AACN, 2004a). • In comparison, the CNS is also prepared at the master’s level but is prepared at the advanced practice level with competencies as outlined in AACN’s (1996) Essentials of Master’s Education for Advanced Practice Nursing (AACN, 2004c) Is CNL an MSN advanced practice role? • AACN is proposing that we move our clinical master’s advanced practice nursing degrees (CNS, NP, CRNA and CNM) toward the practice doctorate. • The CNL will be a Masters prepared nurse • The CNL will serve in a unit-based role in the place of a unit-based CNS and ideally in conjunction with a DNP Is CNL an emerging advanced practice role? • CNL is an emerging nursing role developed by the American Association of Colleges of Nursing (AACN) in 2003 • The expectations for the CNL seem formidable with the many responsibilities identified • CNL role clearly overlaps with the CNS role in many areas. – Both the CNL and CNS manage care that is responsive to the health care needs of individuals and families. – The CNL and CNS design and provide health promotion and risk reduction services for patients. Summary • The CNL is a unique and valuable nursing role • The verdict is still out on recognition of CNL as an “advance practice” role • Standardization and legislation for title recognition and educational requirements is needed to formalize the role Reference AACN, 2008. CNL Frequently Asked Questions. American Association of Colleges of Nursing. http://www.aacn.nche.edu/CNL/FAQ.htm Accessed 9- 29-08. American Association of Critical Care Nurses, 2008. Advanced Practice Roles: CNS or NP? What’s in a Name? American Association of Critical Care Nurses. http://classic.aacn.org/AACN/aacnnews.nsf/ff1487bfe89b77df882565a600 6cfc3f/2ae0e849ab5ec4e188256b5a007cd35e?OpenDocument#roles. Accessed 9-29-08. APRN-JDC, 2008. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory Committee. July, 2008. Grindel C. (2005). AACN Presents the Clinical Nurse Leader and the Doctor In Nursing practice Roles: A Benefit or a Misfortune? MEDSURG Nursing, Vol. 14/No.4, pg 209-210. Reference Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: The National Academies Press. Joint Commission on Accreditation of Healthcare Organizations. (2002). Health care at the crossroads, Strategies for addressing the evolving nursing crisis. Chicago. Kimball, B. & O’Neill, E. (2002). Health care’s human crisis: The American nursing shortage. Princeton, NJ: The Robert Wood Johnson Foundation. Spross J, Hamric A, Hall G, et al. Working statement comparing the clinical nurse leader and clinical nurse specialist roles: similarities, differences, and complementarities. Washington, DC: American Association of Colleges of Nursing; 2004. WDOH, 2005. Nursing Practice Guide. Washington State Department of Health, Nursing Care Quality Assurance Commission. December 2005 Institute of Medicine. (2000). To Err is Human: Building a Safer HealthSystem. Washington, DC: National Academy Press.