Clinical Nurse Leader New Role Focuses on Big Picture

Heather Stringer

Nan Trump, RN, BSN, was working with patients at the Center for Medically Fragile Children at Providence Child Center (CMFC) in Portland, Ore., as part of her graduate residency when she started questioning the nursing night-shift routines. Do we need to wake patients in the middle of the night to turn them, change them, and take vital signs? Would the patient benefit more from uninterrupted deep sleep?

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, FA AN, 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.

NEED FOR CHANGE

The first inklings of the need for a new breed of nurse arose in 1999 after several organizations released reports about the high level of medical errors. The Institute of Medicine issued one of the reports, "To Err is Human: Building a Safer Health System," in 1999. The report stated that, medical errors were not usually the result of "human recklessness," but more com­monly were caused by "faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them."

"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, tbe 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 responsi ble for the unit­based outcomes," says Judith Karshmer, PhD, APRN, dean or 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."

A TEST CASE

Although administrators at Glendale Adventist Medical Center in Glendale, Calif.. were unaware of the CNL concept. six years ago the facility began experimenting with a new nursing structure that has similarities to the new role - and so far, Glendale's model has been highly successful.

"When I first came here seven years ago, I found the typical nursing structure in which a nurse manager was in charge of two or three units," says Gwen Matthews, MSN, MBA, senior vice president and chief nursing officer at Glendale Adventist. "When I asked the staff about their nurse managers, I could see the man­ager had little impact on anyone unit, and they were in meetings all the time. There was not a nursing leader who was in the thick of the operations and day-to-day flow who could take care of problems."

Matthews suggested a model in which a head nurse would be devoted to one unit. The head nurse would be on the floor 24 hours a week and dedicate 16 hours a week to administrative work, such as evaluations, audits, and networking with other depart­ments. A portion of the head nurse's mana­gerial responsibilities - specifically budget preparation and meeting attendance ­would be transferred to the nursing director to free up time for the head nurse to work on the floor and solve problems on the unit.

To decrease fragmentation in patient care, the hospital also started experimenting with hiring four charge nurses - two day nurses and two night nurses - who would be part of the head nurse's leadership team. Rather than selecting from a large pool of nurses with varying degrees of skill, the hospital assigned charge nursing responsibilities by having nurses apply for the four charge nursing positions. To be selected, the nurses had to demonstrate good communication and interpersonal skills. Now that there is a head nurse or one of the four charge nurses on the floor at all times, physicians, nurses, patients, and family members have easier access to someone who can solve problems or answer questions.

Agnes Pagdilao, RN, OCN, head nurse of the oncology unit at Glendale Adventist, has worked at the hospital for 30 years and says nurses are happier now than ever. Staff nurses thrive when there is a nurse in leadership who has the time and motivation to help staff nurses with ques­tions, problems, or concerns, she says.

"So far my job as head nurse has been rewarding because I can see that the nurs­es are happier," she says. "The turnover has been very low. Nurses are my No.1 customer, and the patients are their No.1 customer. If the nurses are happy, it will spill over to the patients."

INCORPORATING THE CNL

Although Pagdilao does not have mas­ter's degree training as a leader, Glendale Adventist's success suggests there is indeed a need for a leader who is also in the trenches. But advocates of the CNL role knew that need was not enough to guarantee a place for the clinical nurse leader in a hospital setting. As a result, the AACN mandated that universities interested in a CNL program must first find practice partners. The universities and the hospitals would work together to design the CNL curriculum and the clini­cal sites, as well as how to provide precep­tors and future jobs for CNL graduates.

"One of the most exciting things I've observed is the partnership and collabora­tion of academia and the practice setting," says Traci Hoiting, RN, MS, ACNP-BC, vice president of nursing practice and opera­tions at Swedish Hospital in Seattle and a member of the AACN's national implemen­tation task force for the CNL role. "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.

RESISTANCE TO CHANGE

Although CNL programs are taking off in some parts of the country, advocates of the new role are facing barriers in other areas.

One 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 ready 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.

SECOND CAREER CNLS

Although the AACN encourages nursing schools to partner with hospitals that will hire graduates of these programs as clinical nurse leaders, Sonoma State is taking a dif­ferent approach.

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.