Molding a New Role
CNLs Emerge in DC/Maryland/Virginia Region
Monday February 9, 2009
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CNLs are master's prepared, hands-on nurses who have passed the national CNL specialty certification exam administered by the American Association of Colleges of Nursing.
"A CNL has a sophisticated knowledge of the evidence for practices that deliver high-quality, safe patient care," says Geraldine "Polly" Bednash, RN, PhD, FAAN, chief executive officer of the AACN.
They are not classified as advanced practice nurses, but CNLs are nurse clinicians who oversee and provide direct care to a specific assignment of patients and assess cohort risk, adjust care plans as needed, and evaluate outcomes.
Unlimited Possibilities
To advance the emerging CNL role, the AACN has launched a national pilot project involving almost 90 education-practice partnerships in 35 states and Puerto Rico.
The pilot's goal is to develop master's-degree CNL programs, integrate this clinician into the healthcare system, and evaluate outcomes.
One of these partnerships is between Inova Fairfax Hospital, Falls Church, Va., and George Mason University School of Nursing, Fairfax, Va.
Kathy Davis, RN, MSN, CNL, who works at Inova Fairfax Hospital, has become the point person for concerns and questions about practice that arise daily. "There are endless possibilities in this role," she says.
Davis is frequently sought out as a resource for learning and keeps busy staff on track with constantly evolving care plans, medications and technology, and evidence-based practice.
When a group of staff nurses wanted to know more about transitioning patients from IV to oral pain medication, Davis arranged for inservices. She also provided information to a nurse who had questions about caring for a patient with metabolic alkalosis. "The purpose of the CNL role is to help shape practice," says Bednash. "CNLs help the staff nurse at the bedside with understanding how to deliver the highest quality and most effective care and monitor the outcomes of that care."
Evidence-Based Care & Hands-On Know-How
CNLs also are key to facilitating collaboration and integrating evidence into effective quality improvement strategies across the spectrum of disciplines.
"One of the most important roles CNLs fulfill is lateral integration – coordinating complex care across the full array of providers," says Bednash. "They are often the only point of continuity for patients."
This can include streamlining care and communication among RNs, advanced practice nurses, physicians, pharmacists, social workers, dieticians, and home healthcare providers. Inova Fairfax CNLs also participate in developing hospital-wide standardized processes to meet core Joint Commission and CMS indicators, such as for pneumonia, heart failure, and surgical infection prevention, according to Patricia Conway-Morana, RN, MAD, NEA-BC, CPHQ, FACHE, the hospital's chief nurse executive.
"They are also excellent in connecting patients to community resources," she says.
In addition, the CNLs' know-how has been welcomed by staff nurses. "They have seen that I am not here just to direct them, but that I help with clinical care," says Davis. "Units with a high turnover of patients and nurses could really benefit from this role."
The VA Puts Out the Call
CNLs have been embraced by the Veterans Health Administration, which plans to implement the role at all sites nationwide by 2016. Currently, about one-third of its facilities employ CNLs, says Cathy Rick, RN, NEA-BC, FACHE, chief nursing officer, VHA, Department of Veterans Affairs, Washington, D.C.
Early data compiled by the VHA is demonstrating reduced complications, shortened length of stay, and improved nurse, patient, and physician satisfaction associated with the CNL role.
"There is no doubt in my mind ... that having a master clinician at the point of care makes a difference in quality and safety every day," say Rick.
The American Organization of Nurse Executives is also optimistic and supportive of CNLs.
"Although the role is still too new to hang everything on it, early results are encouraging, and organizations who have the role working effectively seem to be really pleased with it," says Donna Herrin, RN, MSN, NEA-BC, FACHE, 2009 AONE president.
Demand Surges
CNLs also are being sought out by organizations weathering the current pay-for-performance climate.
Hospitals are finding CNLs are experts in cost-effective resource utilization and streamlining quality care while avoiding pitfall complications such as pressure ulcers and hospital-acquired pneumonia. They also are educated in how to document the cost savings they help produce.
"That makes the CNL a very attractive person to have," says Bednash. "AACN is hearing that some employers are trying to get as many CNLs as they can."
Inova Fairfax has created a clinical ladder program that supports nurses through the educational process and progresses them into the position.
Loretta Brush Normile, RN, PhD, associate professor and coordinator of the CNL track at George Mason, believes the demand for CNLs will increase as the public becomes more familiar with the role.
"Healthcare consumers are getting pretty savvy and are looking to the professional who can bring about safety, positive outcomes, and quality in their care," she says.
More local organizations are requesting information about George Mason's program, says Normile, because of an upswing in CNL interest and to clear up confusion about the distinction between the CNL and CNS roles.
The CNL is prepared as a generalist who is responsible for supervision and delegation of care delivery by staff on a daily basis. The CNS is prepared in a specialty or subspecialty and focuses on process improvements along multiple units, such as for patients with asthma or congestive heart failure, who can be found on many units.
"The CNS is systems-based, while a CNL is unit-based," says Normile. Also, the CNL title is trademarked, and only nurses who have completed an approved CNL master's track and passed the AACN certification exam can use it.
A Hands-On Option
The CNL role is attractive for nurses who want to advance their careers while still participating in the hands-on patient care experience. The ideal candidate is a seasoned clinical nurse who wants to stay at the bedside and has a desire to continue his or her education. "The CNL track is great for RNs who want to pursue a master's degree that has a hands-on, clinical focus on patient safety, leadership, and evidence-based practice," says Normile.
For information, visit AACN at www.aacn.nche.edu/cnl/ Index.htm and George Mason University School of Nursing at Chhs.gmu.edu/nsg/msn-clinicalnurseleader.html.
Catherine Spader is a contributing writer to Nursing Spectrum.
To comment, e-mail editorDC@nursingspectrum.com.
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