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Grace Sotomayor, DNP, MBA, RN, CNL, FACHE, NEA-BC, is Vice President, Administration, and Chief Nurse Executive, Central Division, Carolinas Healthcare System, Charlotte, NC. Veronica Rankin, MSN, RN-BC, CNL, NP-C, CMSRN®, is Clinical Nurse Leader Program Coordinator, Carolinas Medical Center, Charlotte, NC.
Clinical Nurse Leaders: Fulfilling the Promise of the Role
A lthough health care in the United States is the most costly in the world, out-
comes have not kept pace with those of other developed countries (Commonwealth Fund, 2014). The Institute of Medicine (IOM, 1999) described fragmentation of care as a major contributor to 44,000-98,000 deaths each year from medical errors. Ten years later, only modest improvements in error reporting and an increase in quality initia- tives were noted by Wachter (2010). However, the author saw the focus on nursing through public report- ing of nurse-sensitive measures as a hopeful sign. The IOM (2010) also identified nursing as the discipline best able to effect significant change in health care in the United States if certain conditions were met, including advancement of nursing education. With more than 3 mil- lion members, nursing constitutes the largest segment of the health- care provider workforce in the United States (U.S. Department of Health and Human Services Admin - istration, 2014), and has the size to influence care delivery.
An American Association of Colleges of Nursing (AACN) white paper in 2007 proposed a new role in nursing: Clinical Nurse LeaderSM (CNL®). In addition to concern over healthcare outcomes in the United States, the AACN maintained atten- tion needed to be given to needs of an aging population and to the nursing profession.
Some organizations became early adopters of the CNL role (e.g., the Veterans Administration) (Ott et al., 2009]), and several universities part-
nered with hospitals and health sys- tems to prepare CNLs for deploy- ment in varied roles from navigators of high-risk patient populations (Becze, 2013) to point-of-care coach- es and mentors (Reid & Dennison, 2011). However, data on outcomes related to the role continue to be sparse, perhaps because the CNL is the first nursing role to be developed in over 30 years and its long-term impact is yet to be evaluated. Nurse leaders at the program site believe this role holds a great deal of prom- ise in a variety of care environments, and hope the addition of this facili- ty’s experience to the body of litera- ture on the CNL will help promote its continued adoption (Bender, 2014; Bender, Connelly, Glaser, & Brown, 2012; Moore & Leahy, 2012; Wilson et al., 2013).
The Program A partnership to prepare CNLs
was forged in 2008 between the chief nurse executive (CNE) of a Level 1 trauma center and a Magnet®-designated academic hos- pital in the southern United States. The CNE’s goal was to improve qual- ity and safety outcomes on medical-
surgical units. These units had his- torically high RN turnover and a large percentage of new graduate nurses. With a matching grant from the Duke Endowment Foundation, the hospital committed to hiring 36 CNLs over 4 years into clinical lead- ership positions. Substantial prepa- ration was completed with nurse managers, assistant vice presidents (AVPs), nursing staff, physicians, and support teams (e.g., case man- agement, pharmacy, occupational and physical therapy, nutrition serv- ices). Information was shared widely on differences between the CNL and the clinical nurse specialist (CNS), case manager, or clinical supervisor, and multiple opportunities provid- ed for addressing questions.
Nurse candidates for CNL pro- gram participation were selected carefully. Candidates had to be bac- calaureate-prepared, high perform- ers, and lifelong learners who were respected by peers and physicians. Minimum nursing experience was set at 2 years. CNL graduates were expected to have oversight of care for 12-18 patients in a designated unit, perform daily rounds with interprofessional teams, serve as resources to clinical nurses, review
Grace Sotomayor Veronica Rankin
Nurses have the capacity to improve patient care quality, cost, and safety. The role of Clinical Nurse LeaderSM in improving care and reducing costs in a Magnet®-designated Level 1 trauma center in the southern United States is described.
Instructions for Continuing Nursing Education Contact Hours appear on page 24.
January-February 2017 • Vol. 26/No. 122
patient outcomes, and teach change management and evidence- based practices to nursing teams. Units selected for role implementa- tion were considered ready for change as evidenced by staff will- ingness to revise their care delivery model to have each clinical nurse assume responsibility for an addi- tional patient to accommodate the addition of CNLs into the team. The CNE, CNL coordinator, and AVP leading the program held multiple meetings on all shifts. The program began with a five-nurse cohort as the minimum number the universi- ty needed to support its investment.
During their final school year, aspiring CNLs received 2 days of exposure to the hospital’s CNE and chief medical officer, as well as to quality, patient experience, case management, and financial leaders, to gain understanding of organiza- tional goals and important concepts (e.g., value-based purchasing, pay for performance, population health). They then were placed in the role of patient care leader (PCL) as a precur- sor to the CNL role. Their capstone projects reflected the goals of the units on which they worked and they were precepted by the program coordinator, an advanced practice nurse, or an experienced CNL. After graduation, each CNL was assigned as an attending nurse to a cohort of 12-18 patients.
The facility now has 35 CNLs and 2 PCLs. Several incumbents have been identified as candidates for the role in future academic years. The role is well respected by physicians and nursing staff, and requests have been received to expand the pro- gram to pediatrics and other service lines. Facility leaders support the role by investing in an RN Graduate Loan Forgiveness Program, which awards loans of up to $15,000 to selected CNL applicants. Loans are associated with a 5-year work com- mitment agreement. Administrators and nurse managers recognize the value of this role because CNLs have facilitated achievement of specific outcome measures and the program was designed to be neutral to each unit’s budget.
Results From 2010 to 2015, CNLs led
substantial reductions on medical- surgical units to which they were deployed. Improvement in the inci- dence of patient falls, catheter-asso- ciated urinary tract infection, cen- tral line-associated blood stream infection, and hospital-acquired pressure ulcers ranged from 30% to 82% (see Figure 1).
In addition to these improve- ments in nurse-sensitive indicators, quality and cost metrics on specific medical-surgical units are being impacted through improved man- agement of high-risk, high-cost patient groups. Involved patients rarely have a single disease, and their complexity exacerbates the inherent fragmentation of health care. While CNSs are focused on particular disease states, the gener- alist preparation of the CNL appears to be suited better to successful inte- gration of care across multiple set- tings. Interprofessional coordina- tion is evidenced by outcomes in the following examples.
Renal Transplant In fall 2012, a CNL and perioper-
ative CNS led a process to change
the care location of patients imme- diately following renal transplant surgery from the Surgical Intensive Care Unit (ICU) to a general med- ical-surgical unit. Eight acuity- adaptable beds were created and the first patients were seen in March 2013. Because ICU cost was elimi- nated, direct variable nursing cost per patient day was reduced 50.9% (from $727.03 to $356.67). In addi- tion, 23% reduction in total vari- able cost per case was achieved in 2015, compared to costs from 2012 (see Figure 2). In addition, positive gains were seen in average length of stay (ALOS) as well as mortality and readmission rates.
Trauma A small segment (3%) of trauma
patients at the program site accounts for 13% of overall cost of care. Patients requiring tracheo - stomies were outliers in 2012 as per- formance was evaluated against best-practice benchmarks. Their care was being delivered in the Emergency Department (ED), oper- ating room, surgical trauma ICU (STICU), and the trauma stepdown medical-surgical unit. Varia tion was identified in trauma surgeon as well
FIGURE 1. Reduction in Adverse Events 2010-2015 with Implementation
of CNL Role
F a v o r a b l e
CAUTI = catheter-associated urinary tract infection, CLABSI = central line-associated blood stream infection, HAPU = hospital-acquired pressure ulcers
January-February 2017 • Vol. 26/No. 1 23
as nursing and respiratory therapy practice.
The CNL from the trauma step- down unit began working in November 2013 with the trauma team and nurses from the STICU to develop a tool to identify patients likely to need a tracheostomy. Pathway integration with a focus on decreasing time-to-tracheosto- my was initiated and the CNL served as the clinical navigator across various microsystems in - volved in each patient’s care. The team began measuring outcomes using observed-to-expected length of stay for these patients because their initial assumption was all patients would fall into diagnostic- related groups 3 and 4. However, manual records review found con- sistent efforts to ensure aggressive intubation, early tracheostomy, ventilator weaning, and early reha- bilitation often led to a change in discharge diagnoses, making elec- tronic data retrieval challenging. The team now has created a patient registry and performance is calcu- lated patient-by-patient using raw ALOS data. ALOS in 2014 for all patients was 33 days; as of mid- October 2016, ALOS was 18 days. This represents 506 saved days with cost decrease of $1,558,480.
Home Ventilator Patients Similar to many large centers that
provide complex tertiary and quater- nary care, the project site operates at a 95%-98% occupancy (A. Conley, personal communication, October 11, 2016). Patients in ICU are trans- ferred to a 19-bed progressive unit when they are considered too unsta- ble for a medical-surgical unit. However, the progressive unit usually has 100% room usage, causing delayed transfers from the ICU. In 2014, three CNLs in one of the gen- eral medical units developed a phased plan to move a subset of pro- gressive unit patients on home venti- lators to their unit. Phase 1 would move patients already in the progres- sive unit and phase 2 would move patients from the medical ICU bypassing the progressive unit. In phase 3, appropriate patients would be moved from the ED, bypassing the ICU and the progressive unit. During phase 4, the unit would accept direct- ly admitted patients. The facility cur- rently is in phase 2 and early results are promising for cost, clinical out- comes, and ALOS related to phase 1. Since January 2015, 24% reduction in total direct variable nursing cost per patient day has been realized (from $648.60 to $492.72) and total ALOS for patients with home ventila-
tors has dropped from 35.5 days to 23.5 days. Of 15 patients who have been transferred from progressive care, only two returned to the ICU. The unit continues in phase 2 and is being evaluated for its ability to man- age other types of patients from the stepdown ICU.
High-Risk Obstetrics The high-risk antepartum unit is
the medical-surgical unit for preg- nant women with complex medical conditions potentially dangerous to mother and baby (e.g., gestational diabetes, obesity, hypertension). Two CNLs in the maternity program have intervened to improve care by link- ing their efforts from outpatient to inpatient. One focuses on support in the outpatient arena by establishing a trusting relationship with patients and families; educating patients; encouraging adherence to prenatal classes, prescribed medication, diet, and exercise; and making regular patient progress calls. The inpatient CNL assumes responsibility when a patient is admitted for delivery or medical management. The CNLs also led the 2014 development of cross-continuum clinical pathways for hypertension and diabetes in pregnancy to achieve normal to near-normal blood glucose and blood pressure to improve perinatal outcomes. Patients are followed from the prenatal visit in the obstet- ric clinic to 6 weeks postpartum.
Case studies to date show prom- ise. For example, a patient with type 1 diabetes and osteogenesis imper- fecta had nine admissions to manage blood glucose with a prior pregnan- cy; she also experienced recurrent urinary tract infection and hydronephrosis requiring a neph - rostomy tube. She spent 82 days in the hospital and her baby had to remain in the neonatal intensive care nursery (NICN) for 2 weeks. She enrolled in the CNL program for her most recent pregnancy and delivered a healthy baby with no NICN stay. While the patient’s admissions for medical management only were reduced to six, the length of stay for this birth was 15 days (82% reduc- tion from prior pregnancy).
Clinical Nurse Leaders: Fulfilling the Promise of the Role
FIGURE 2. Kidney Transplant: Variable Cost Savings per Case 2012-2015
F a v o r a b l eC
os t p
2012 2013 2014 2015
23% reduction in variable costs/case = $13,463 savings per case
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Next Steps Facility leaders continue to iden-
tify ways CNL intervention may improve cost and quality of care. One team of CNLs is learning LEAN skills (Scoville & Little, 2014) and co-leading development of inter- professional rounds with hospitalist physicians. Another is spearheading aggregation of hepatobiliary pa - tients to improve care outcomes. A third pair of CNLs is working with hospitalists and the site’s ED team to identify and transfer patients who meet criteria for care at one of the system’s community hospitals to decompress the main campus. The role will be extended to evening and weekend shifts, and possibly to other service lines (e.g., cardiac, pediatrics). The CNL cur- riculum is updated regularly with academic partners so information and practice remain current. In addition, the CNE and program coordinator meet quarterly with the dean of the partner college and pro- fessors teaching the CNL courses to apprise them of facility goals and ongoing and potential changes.
Lessons Learned Nurse leaders in the clinical set-
ting must have a vision for CNL function and how to measure the impact. Workload must be manage- able and deliberate steps taken to clarify for all stakeholders what the CNL role is and is not. Candidates for the role must be selected very carefully with examination of each nurse’s motivation for wanting to become a CNL. Two failures from the program were related to deficits in critical thinking and test-taking ability, reinforcing that desire to be a CNL is only one quality for candi-
date consideration. High intelli- gence and the ability to work with others through influence and under stress are also essential. Additional work needs to be done to determine which opportunities to improve patient care may benefit most from CNL attention.
Conclusion The AACN (2007) emphasized
the CNL role addresses the call for changes that are necessary for the country to address challenges faced in health care. Authors have found this to be true at the project site. The generalist training of the CNL positions the nurse well for clinical leadership at the microsystem and mesosystem levels.
REFERENCES American Association of Colleges of Nursing
(AACN). (2007). White paper on the edu- cation and role of the clinical nurse leader. Retrieved from http://www.aacn. nche.edu/publications/white-papers/ ClinicalNurseLeader.pdf
continued on page 32
Instructions For Continuing Nursing Education Contact Hours
Clinical Nurse Leaders: Fulfilling the Promise of the Role
Deadline for Submission: February 28, 2019 MSNJ 1702
To Obtain CNE Contact Hours 1. For those wishing to obtain CNE contact hours, you must read the article and
complete the evaluation through the AMSN Online Library. Complete your evaluation online and print your CNE certificate immediately, or later. Simply go to www.amsn.org/library
2. Evaluations must be completed online by February 28, 2019. Upon completion of the evaluation, a certificate for 1.2 contact hour(s) may be printed.
Learning Outcome After completing this learning activity, the learner will be able to discuss how clinical nurse leaders can improve patient outcomes and reduce costs.
Learning Engagement Activity Download and review: American Association of Colleges of Nursing (AACN). (2007). White paper on the education and role of the clinical nurse leader. http://www.aacn.nche.edu/publications/white-papers/ClinicalNurseLeader.pdf
The author(s), editor, editorial board, con - tent reviewers, and education director reported no actual or potential conflict of interest in relation to this continuing nursing education article.
This educational activity is jointly provided by Anthony J. Jannetti, Inc. and the Academy of Medical-Surgical Nurses (AMSN).
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High intelligence and the ability to work with others through influence
and under stress are also essential.
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Clinical Nurse Leaders continued from page 24
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