In 2003 the American Association of Colleges of Nursing (AACN) developed the Clinical Nurse Leader (CNL) role, the first new nursing role since the nurse practitioner role was developed in the 1960s. Today, there are about 2,500 board-certified CNLs in the country—including 14 at Trinity Health Saint Mary’s in Grand Rapids, Mich.
Two nurse leaders from Saint Mary’s joined us this past spring in a member spotlight webconference to discuss how they implemented the role and the results they’ve seen. We spoke with:
Read on to learn more about the CNL role.
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For those who aren’t as familiar with the Clinical Nurse Leader role, could you provide a brief background on the role?
In 2003, the AACN brought together leaders from academia and health care practice to consider new educational programs to meet existing needs and plan for nursing’s future—particularly in light of the Institute of Medicine’s 1999 report, To Err is Human: Building a Safer Health System. It was a call to action to deliver safer, better quality care, while also addressing rising health care costs.
The CNL is a clinical care coordinator working within a microsystem, such as a unit. He or she is responsible for integrating care, managing outcomes for patients, and working to improve system processes of care. The AACN formally codified the role in a 2007 white paper.
What was your goal for the CNL role at Saint Mary’s?
It was obvious to us that there were gaps between the care we intended to deliver and the care we were actually delivering. We had a few small tests of change that had been successful in the short-term, but we hadn’t been able to sustain the changes.
We also recognized that while our overall outcomes were very strong, we had not accomplished all we set out to do within each individual unit or patient population. So we wanted someone focused on managing outcomes with the ability to improve processes at the unit or microsystem level—while also making sure care was cost-effective.
We envisioned the CNL fulfilling these roles:
- Clinical care coordinator for a specific population, most often on a particular unit
- Outcomes manager—clinical, service, and financial—for the population
- Educator and mentor for clinical nurses through one-on-one coaching and just-in-time intervention
- Care team leader responsible for helping all staff learn about quality and performance improvement
- Advocate for patients, families, and staff
- Information manager to analyze nursing-sensitive outcomes and processes
How did you prepare staff to become CNLs?
Trinity Health partnered with the University of Detroit-Mercy to develop and implement the CNL curriculum. At the time, Tricia was a faculty member at the university, and she worked with several Trinity Health nursing leaders to develop the CNL program—the first of its kind in Michigan.
Trinity provided full scholarships to 40 students from six hospitals to earn their CNL certification. We sent 17 students from Saint Mary’s. They had a variety of backgrounds: staff nurses, nurse educators, assistant managers, and case managers. The students went through the 18-month program together as a cohort.
Most of Saint Mary’s CNL students worked for us full-time while going to school. All of their projects were geared around specific issues at our organization, so the work they did during school helped us improve even before they graduated.
Besides their formal education, what other training did Saint Mary’s CNLs receive?
We wanted to help them connect the dots between their academic education and Saint Mary’s specific circumstances—for example, where we stood with Core Measures and what our targets were. We also trained them on how to access all of the data they would need to identify improvement opportunities.
Additionally, the CNLs received training in the following areas:
- Systems thinking
- Coaching skills
- Crisis prevention and de-escalation
- Palliative care and pain management
- Crucial Conversations
- Lean tools and methodology for performance improvement
Where did you place CNLs throughout the organization?
We have 14 CNLs across Saint Mary’s (a health system with a 377-bed teaching hospital and more than 300 employed providers). We have 11 unit-based CNLs, one in the Emergency Department (ED), and two who focus on specific populations across the continuum: patients with diabetes, and patients with complex care needs.
We intentionally did not place CNLs in the clinical areas where they had worked prior to earning their certification. We wanted to make sure staff saw them as CNLs—not as the nurses or educators or case managers they were previously.
The CNL role is designed to be a generalist role when it comes to particular clinical specialties, and a specialist in systems thinking, process improvement, and seeing the work through different eyes. So we placed a former critical care expert on our psychiatric medical unit. A former neuroscience clinical expert went to our orthopedic unit.
Six months after introducing the role, we talked with each CNL in a structured interview to evaluate the onboarding process. Although most hadn’t been thrilled by their initial placement, all of them felt moving to a new unit had forced them to fully assume the clinical nurse leader role—rather than simply being a better nurse in their previous unit.
How did you differentiate the CNL role from other roles on the care team?
We spent a lot of time on this issue not only with the CNLs but also with other members of the care team. Some staff feared the CNLs were replacing case managers and educators. We created Venn diagrams showing how each role was distinct—and explained that the small area of overlap between the roles wasn’t a bad thing, but should help with care coordination. CNLs decide which patients they are most involved with on the unit based on complexity and risk stratification, yet have knowledge about all patients.
The CNLs created a brochure to explain the new role to physicians and staff. We told them to spend 100% of their first 30 days in the role observing care on the unit and building relationships with staff. They needed to meet all staff on all shifts, along with key physicians, to build clinical credibility.
Who do CNLs report to?
We want CNLs to partner with unit managers as equals, so they report to the clinical service director (instead of the unit manager). The goal is to ensure the CNLs feel comfortable raising issues that need to be addressed on the unit with the unit manager.
The organization gave you a mandate to implement the CNL role without increasing the total number of employees. How did you accomplish this?
We had to re-think how other roles would change once the CNL role was implemented. For example, we realized we wouldn’t need as many educators because the CNL would be working with staff at the bedside. We also decided to eliminate our assistant nurse manager role—the business aspects of the role could be assumed by the unit manager and the CNL would take on the clinical leadership piece.
In the end, no one lost their job due to the changes. Among our six assistant nurse managers, four entered the CNL program, one transitioned into an educator role, and another moved back to a staff nurse role. Two educators also completed the CNL program.
What ongoing support do you provide to the CNLs?
When the CNLs were in school, we paired each one with a clinical nurse specialist (CNS) or Master’s-prepared director to serve as mentors. We also assigned each CNL one of our Lean consultants to coach them through their education and provide ongoing support after graduation.
We have monthly meetings with all CNLs, the director lead, and the CNO to discuss the role and how it’s working. CNLs are considered part of our overall leadership team for communications and staff development, yet we have maintained a commitment to having them spend 80% of their time on the units and engaged at the point of care.
What were some of the challenges you faced when first introducing the CNL role?
There were a few different issues we had to work through:
- Ensuring CNLs did not receive a patient assignment. It was critical to make sure the CNL was not simply a staff nurse with more education. They never receive patient assignments, which was difficult in the first month when there was a high census and managers wanted to pull CNLs into direct care.
- Addressing fears that the CNL role would eliminate the need for other roles. Case managers in particular were concerned that the CNLs would take over their roles. We had to spend a lot of time assuring them that even though the implementation of the CNL role was going to be budget-neutral, the positions weren’t coming out of case management. Case managers remain focused on utilization review and discharge planning, while CNLs focus on care coordination.
- Helping frontline managers view CNLs as partners. We worked hard to differentiate the CNL role from the case manager, educator, and CNS roles, but in hindsight, we didn’t prepare nurse managers sufficiently. Not all frontline managers immediately saw CNLs as a new partner for them who could help move the bar for their unit.
What types of outcomes have you seen at the unit-level since introducing the CNL role?
The psychiatric medical unit is a great example: the length of stay on the 20-bed unit decreased from an average of 19 days to 15 days, thanks to work by CNLs. The unit was admitting an increasing number of patients with end-stage dementia who were transferred from long-term care settings and hospice. Some of them were dying on the unit because they were at the end of the disease process.
The unit’s CNL partnered with the ED’s CNL and the complex care CNL to address the issue. They created an algorithm to screen patients for admission to the unit and created a system for patients to transition to palliative care or hospice as appropriate.
What outcomes have you seen from CNLs’ work with complex patients?
The complex care CNL and ED’s CNL led a process of analyzing data for patients who had been in the ED five or more times in the past year or who had four or more admissions in the past year. They chose 12 patients as an initial sample for intervention. They created complex care plans for these patients by collaborating with primary care providers, home care, specialists, hospital staff, patients’ families, and community agencies.
The complex care plans are built within our electronic medical record (Cerner). When one of these 12 patients is admitted, the plan pops up. Not all of our primary care offices are connected to our EMR, so the team also created a series of “stoplight” tools to help direct patients to the appropriate care setting.
The patient and each of the primary care, specialty care, and community agencies working with the patient received a customized stoplight tool defining what action should be taken when. The team interviewed each patient to customize the stoplight tool: For this patient, what does green, yellow, and red look like?
Yellow is when he starts feeling the symptoms that have led to an admission in the past. The stoplight tells him who to call—for example, the primary care office. When he calls, the primary care staff can pull up their version of the stoplight, which explains what to do (depending on the symptoms the patient reports). Each specialist has the tool as well, so the patient will get a consistent message.
In the 12 months before the intervention, the 12 patients had 133 total ED visits and 66 inpatient admissions. In the 9 months following the development of complex care plans, the 12 patients had a total of 12 ED visits and 6 inpatient admissions. The cost savings resulting from avoided utilization is estimated at $325,000.
What organization-wide outcomes have you seen since implementing the CNL role?
On an organization-wide scale, we’ve seen several improvements since 2010 when CNLs were first introduced, including:
- Percentage of RNs with a Bachelor’s of Science in Nursing (BSN) degree and specialty certifications
Through coaching and mentoring nurses, as well as role modeling for them, the CNLs encourage professional development. They have worked with our clinical nurse specialists and professional development specialists to offer educational programs focused on specialty certification and facilitate study groups for nurses.
The number of RNs with BSNs has increased from 350 in 2010 to 430 in 2012 (69% of RNs now have a BSN), and the number of specialty-certified staff has increased from 87 to 138.
The score on pain control has increased from 61 to 73, and the “would recommend” score has increased from 72 to 78.
- Joint Commission Certification for Inpatient Diabetes
The CNL working with diabetes patients across the continuum partnered with a CNS to create processes and systems for improvement which led to the attainment of Joint Commission certification for inpatient diabetes care—the first such designation in Michigan.
RN turnover was fairly stable at about 12% in 2010 and dropped to 7% for the past 18 months.
Trinity uses a balanced scorecard with 34 individual metrics measuring clinical processes, patient safety, patient experience, and nurse staffing. Saint Mary’s GPA went from 2.8 in 2010 to 3.7 in 2012—the highest GPA among Trinity Health hospitals of similar size and complexity.
Saint Mary's successfully achieved Magnet designation in May 2013. Many exemplars in our document came from work lead by CNLs and enhanced clinical outcomes.
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