Clinical Nurse Leader

1. Clinical Nurse Leader An Emerging Advance Practice Role

2. 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

3. 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

4. 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

5. 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

6. 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.”

7. 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

8. 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)

9. 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.”

10. 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

11. 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

12. 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

13. 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)  

14. 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.

15. 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).

16. 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.

17. 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

18. CNL Variations

19. AACN’s White Paper on The Role of the Clinical Nurse LeaderAACN’s White Paper on The Role of the Clinical Nurse Leader

20. 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)

21. 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.

22. 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)

23. 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

24. 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.

25. 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

26. 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/ff1487bfe89b77df882565a6006cfc3f/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.

27. 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.