New Clinical Nurse Leader Role Focuses on Big Picture
Saturday April 14, 2007
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Nan Trump, RN, BSN, Center for Medically Fragile Children at Providence Child Center, Portland, Ore.
(Photo by Jeffrey Krausse.)
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Trump, who has been a nurse for three decades, is being trained to step out of the daily grind and ask why. She is one of eight nurses in the first cohort of students at University of Portland who will graduate in May as clinical nurse leaders, or CNLs. Her school is among the first on the West Coast to create a CNL program, a six-semester master’s degree curriculum that prepares nurses to combine time at the bedside with leadership skills to identify and solve problems.
The American Association of Colleges of Nursing (AACN) designed the CNL role in response to national reports that highlighted poor patient outcomes. To improve patient safety, these reports called for the healthcare workforce to re-examine how it was educating people to enter the field. In response, the AACN started investigating how nursing could respond to these national concerns. Many meetings and task forces later, they created a new nursing role: the clinical nurse leader.
The AACN envisioned a nurse who would have the training and the time to examine the bigger picture and instigate changes that are needed on a unit. Unlike many nurse managers, the CNL would not be mired in managerial, fiscal, or human resource responsibilities. And unlike staff nurses, CNLs would not provide the daily care for patients, but could instead oversee a subset of nurses and know the history and status of each nurse’s patients.
“I can guarantee you that these CNLs will have the knowledge to look at problems on the unit level and fix those problems,” says Terry Misener, RN, PhD, FAAN, dean of the School of Nursing, University of Portland. “They will be a constant on the unit, having 24-hour responsibility. They can do things like decrease infections, falls, and length of stay, and increase patient satisfaction, family satisfaction, nurse satisfaction, and physician satisfaction.”
The CNL has been likened to nurse practitioners, who pioneered a new breed of nurse in the 1960s. Some hospitals are welcoming the new role, while others are slow to warm up to the idea. But advocates are confident that as CNLs graduate and begin to work with nurses, physicians, and patients, CNLs will prove their value.
“The AACN board of directors wanted to respond to these national concerns and investigate what nursing could do to address them,” says Joan Stanley, PhD, CRNP, FAAN, senior director of education policy for the AACN.
In 2001 the AACN formed a task force that was charged with looking at what competencies the nurse of the future would need, and in May 2003, the task force issued a working paper that described the need for a clinical nurse leader and the skills and training a CNL would need.
“A CNL doesn’t manage the nurses on the unit, but is responsible for the unit-based outcomes,” says Judith Karshmer, PhD, APRN, dean of the nursing school at the University of San Francisco. “She would ensure that patients are being cared for based on evidence.”
For example, if the CNL was in charge of discharging a diabetic patient and the patient received the wrong lancets from the pharmacy, a good CNL would respond by looking at the larger issues involved in this mistake.
“A good CNL would see that this is a systems problem that involves the dynamics between the pharmacy, the unit, the prescribing physician, etc.,” Karshmer says. “The CNL would see that this delayed the discharge by several hours, which is costly to the institution and family. A CNL might meet with everyone to figure out the glitch in the system, because the CNL is focused on how to fix things that impact the unit.”
“It is powerful to put the best thinking from academia and practice together to develop a role in nursing that will address many of the issues in the practice setting.”
Trump, who has been working full time in the neonatal intensive care unit at Providence St. Vincent Medical Center in Portland, Ore. while she earns her master’s degree, is finishing her CNL residency at CMFC, which is within the Providence Health System. Both Providence and the Portland Veterans Affairs Medical Center partnered with the University of Portland to implement the CNL role. When Trump was deciding on a research project, she read articles and talked to nurses to determine which topic was most compelling.
“I realized that sleep was a huge issue,” she says. “As nurses, we are really focused on trying to get our tasks finished, but there are a lot of little things we do during the night that keep our patients awake. Many things during our shifts are done for the convenience of the healthcare worker, but we need to be asking ourselves, ‘How is this going to improve my patient’s outcome?’ and keep the patient at the center of everything we do.”
During her research project, Trump plans to incorporate the use of red lights instead of fluorescent lights, administer melatonin to the children to help them fall asleep more quickly and experience a deeper sleep, and only change patients’ positions and diapers as needed instead of every two hours. She will study whether these changes increase the amount of awake time and level of alertness for the children during the day. She will also examine whether uninterrupted sleep decreases the number of seizures.
Trump, who started her CNL program in January 2005, will graduate in May, and she looks forward to being hired as a clinical nurse leader within the Providence Health System.
Terry Miller, RN, PhD, dean of the School of Nursing at Pacific Lutheran University in Tacoma, Wash., found that facilities were interested in the idea of a CNL, but when it came to the fiscal factors involved in piloting a new role, the discussion came to a halt.
“[The CNL role] may be a necessary cost, but hospitals have to weigh every decision as far as the cost versus the benefit,” Miller says. “I think the CNL is a wonderful program, but I have not seen a significant push in this region to make [the CNL role] a reality.”
Another challenge is finding acceptance for a new role among existing nurses. Critics of the CNL concept suggest that it overlaps with other roles.
“Clinical nurse specialists were initially threatened, as well as other staff nurses,” says Stanley, the AACN senior education policy director. “They wondered, ‘What are [CNLs] going to do,’ whether it would overlap with staff nurses and CNSs, but in fact these roles all complement each other. At the local level we are hearing that overlap has not been a problem.”
Misener, at University of Portland, carefully planned a way to ensure that the first CNLs would have a good chance of being accepted once they finished their master’s programs. He decided to have the first cohort of CNLs be seasoned nurses who were returning to school, and they could pave the way for the second cohort, which would be second-career nurses who did not have previous nursing experience.
“We chose that because we were not going to make the mistake that other pioneers have made,” he says. “I knew we would need some effective role models, because I didn’t want the first comment from people to be, ‘These are not experienced RNs, so how can they do this?’”
The fact that the CNL role is meeting resistance in some regions is not surprising to Melissa Vandeveer, PNP, PhD, associate professor and director of the direct-entry MSN program at Sonoma State University in Northern California
“What’s happening nationwide is similar to the evolution of the nurse practitioner role,” she says. “When it was first initiated in the 1960s, it was slow going. People didn’t know how it fit into the system or the benefits, but now it is flourishing. There are always going to be early adopters and late adopters, and I see this as normal when you consider role adaptation.”
The first CNLs graduated in fall 2006, and so far there are about 130 CNLs throughout the nation, Stanley says. According to a CNL task force report from the AACN, about 90 nursing schools are collaborating with healthcare facilities to implement CNL programs nationwide.
The second-career Sonoma State graduates are being hired as staff nurses, and they are finding creative ways to exercise their CNL leadership skills. Even though the AACN does not encourage this path, hospitals in the north San Francisco Bay Area did not have the financial freedom to finance a new CNL role within their systems, Vandeveer says. She also believes these second-career CNLs benefit from the staff nursing experience.
Barbara McCamish, RN, MSN, CNL, is a second-career nurse who finished her clinical nurse leader program at Sonoma State in May 2006. A month later she was hired as a staff nurse at Queen of the Valley Medical Center in Napa, Calif., and she was looking for a way to incorporate her leadership training into her job.
During the orientation for new graduates, she was introduced to the quality nurse manager, who was planning to reinitiate a Falls Task Force that would work to reduce the number of patient falls and improve the hospital’s falls policy.
McCamish, who was previously a physical therapist, works part time on the orthopedic floor and spends about five hours a week working on the Falls Task Force. She is paid from a different hospital budget for her time on the task force.
“Even though I am a staff nurse, my CNL program allowed me to feel comfortable taking an informal leadership role,” she says. “I really enjoy it.”
And as with any new role, the true litmus test is whether the CNLs are making a difference among physicians, patients, and other nurses. McCamish’s participation in the task force made an impression on the head of the task force, Maureen Plumbstead, RN, BSN, MBA, CPHQ. When the task force was examining the hospital’s falls scales, for example, McCamish was quick to research the data and report it back to the committee.
“I’ve been really impressed by her,” Plumbstead says. “What is unique is her knowledge and focus on evidence-based research. She has a genuine interest in and commitment to advancing nursing practice.”
Advocates of the CNL role hope that Plumbstead’s positive response to a new CNL graduate is only the beginning. They are optimistic that as in McCamish’s case, each CNL’s contributions to the healthcare system will win over physicians, nurses, and patients, and hospitals will find a way to incorporate this new role on units throughout the country.
Heather Stringer is a freelance writer. To comment on this story, send e-mail to editormtw@nurseweek.com.
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