Clinical Nurse Leader–Integrated Care Delivery: An Approach to Organizing Nursing Knowledge Into Practice Models That Promote Interprofessional, Team-Based Care

Predictors of Clinical Nurse Leader implementation success across a national sample of settings: A Bayesian multilevel modeling analysis

INTRODUCTION

The Clinical Nurse Leader (CNL) care model is a different way of organizing frontline nursing care delivery in contrast to the traditional "staff nurse" model and is increasingly being adopted by health systems across the United States and abroad. However, variability in implementation and outcomes has been noted across health settings.

AIM

A recently validated CNL Practice Model provides an explanatory pathway for CNL model integration into practice. The purpose of this study was to identify and compare patterns of empirical correspondence to the CNL Practice Model and predict their influence on implementation success.

METHODS

We conducted a secondary analysis of a 2015 national-level study with clinicians and administrators involved with CNL initiatives in their health system. A psychometrically validated CNL Practice Survey was used to collect data measuring the presence (0%-100%) of the five domains of the CNL Practice Model (organizational readiness, CNL structuring, CNL practices, outcomes, and value) and one measure of CNL implementation success. We modeled the complex hierarchical structure of the data using a Bayesian multilevel regression mixed modeling approach. A zero-one-inflated beta distribution, a mixture of Bernoulli distributions for the minimum and maximum responses and a beta distribution for the responses between the minimum and maximum, was used to fit success ratings in the model.

RESULTS

A total of 920 participants responded, 540 (59%) provided success scores. The model captured ratings skewed toward upper bound, while also adequately modeling data between the minimum and maximum values. The Bayesian model converged and gave estimates for all hierarchical parameters, which would likely have failed to converge in a pure maximum likelihood framework. The variability around success score across CNL Practice Model element ratings was greatest at the component level, 0.29 (0.18-0.48), compared to either the domain level, 0.16 (0.01-0.54), or the item level, 0.09 (0.01-0.17). The components most predictive of implementation success were (a) consensus CNL model can close gaps, (b) organization level implementation strategy, and (c) alignment of empirical CNL microsystem level structuring to the model's conceptualization.

CONCLUSIONS

Findings provide further empirical evidence to support the explanatory pathway proposed by the CNL Practice Model and identified specific organizational readiness and CNL workflow structures that are critical antecedents predictive of CNL practice manifestation and production of expected outcomes. Findings indicate actionable implementation evidence that can be successfully adopted across real-world healthcare settings to achieve safer and higher quality patient care.

CLINICAL RELEVANCE

CNL integrated care delivery is a frontline nursing care model that is being increasingly adopted by health systems across the United States and abroad. However, variability in CNL implementation and outcomes has been noted across health settings, limiting its evidence base. Findings of this study contribute a better understanding about the variability of CNL practice and outcomes found in the literature and contribute empirical and conceptual clarity about the relationships between modes of CNL implementation and successful adoption in healthcare settings.

Enculturating, embedding and investing in fundamental care in an academic health science centre

AIM

This manuscript aims to provide a discursive description of how one academic health care centre is enculturating, embedding and investing in the fundamental care framework and lessons learned that can serve as a blueprint for other organizations.

BACKGROUND

A call to action to focus on fundamental care is not new as the initial Fundamentals of Care (FoC) Framework has been evolving over the last decade through efforts lead by the International Learning Collaborative (ILC). Now more than ever, there is a pressing need for leaders to influence a humane, compassionate evidence-informed approach to the COVID-19 pandemic and beyond by embedding an FoC framework and focusing on fundamental care as part of their academic mandate and daily care practices.

DESIGN

This discursive paper delineates an evolving and ongoing enculturation, embeddedness and investment in advancing fundamental care as part of a larger academic practice strategy and quality improvement plan that is evidence-informed and collaborative in nature.

METHOD

The action framework (value, talk, do, own and research fundamental care) developed by ILC guides efforts to how the FoC framework was embedded into one academic health science centre's strategic directions, academic practice strategy, professional practice model, quality plan and research and innovation platform.

CONCLUSION

An overview of how we leveraged the FoC and ILC Leadership frameworks in our efforts to enculturate, embed and invest in advancing fundamental care and lessons learned that may inform other healthcare organizations in their efforts.

IMPACT ON NURSING SCIENCE, PRACTICE OR DISCIPLINARY KNOWLEDGE

Underpinning all of our efforts is the integral value we place on fundamental care to guide how we practice, educate and learn, discover and innovate and lead at x. We shared how we value, talk, do, own and research fundamental care by having it embedded into our strategic directions, academic practice strategy, professional practice model, quality aims and research and innovation platform.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

A clinical nurse leader competency framework: Concept mapping competencies across policy documents

To ensure Clinical Nurse Leaders (CNL) are prepared to function to the full scope of their master's level education, the American Association of Colleges of Nursing published a 2007 White Paper and a 2013 update articulating expected end-of-education and CNL practice competencies. The Commission on Nurse Certification published a CNL job analysis in 2016, which identified a core set of knowledge, skills, and abilities for entry-level practicing CNLs, as the basis for the CNL certification exam. While all share core themes, the language and organization of competencies differs across the three policy documents, resulting in potential ambiguity about expected CNL knowledge and practices, and how they differ from other nursing roles. This effort identified, analyzed and synthesized CNL education and practice concepts listed in each document to refine understanding about CNL competencies and harmonize concepts across documents. The product of this effort is a cohesive CNL competency framework that aligns across the education-to-practice trajectory. The CNL competency framework can be used to guide CNL curriculum and certification review, and may have use in implementing and evaluating CNL practice integration.

Impact of Structured Nurse Leader Rounds on Satisfaction With Nursing Care Among Patients With Cancer

BACKGROUND

The patient satisfaction rate is considered a challenge for nurse leaders, especially among patients with cancer, due to the complexity of the disease, diagnostic procedures, and treatment.

AIM

The purpose of this study was to evaluate the impact of structured nurse leader rounds (NLRs) on satisfaction with nursing care among patients with cancer. Moreover, we assessed the relationship among NLRs, patient satisfaction, and demographical variables.

METHODS

A two-group posttest design was used in four adult inpatient oncology units in a specialized oncology center. A stratified random sampling technique was utilized to select 169 patients for the experimental group (80 patients) and control group (89 patients). Structured leader rounds were conducted by nurse leaders using a scripted nurse leader tool to standardize the rounds in the experimental group, while the unstructured leader round was conducted in the control group. Patient satisfaction was measured using the Patient Satisfaction with Nursing Care Quality Questionnaire.

RESULTS

The findings revealed that there was a significant difference in total score of patients' satisfaction between study groups (t = -9.213, p > .001). Conversely, the structured leader round has a significant impact on the patient's experience with nurse concern and caring (t = -2.054, p = .042).

CONCLUSIONS

Adoption of a structured NLR has a significant impact on improving patient satisfaction in an oncology setting where patients receive care from many disciplines, such as surgical, medical, radiotherapy, and radiology.

CLINICAL RELEVANCE

Efficient structured NLRs of nursing professionals are important for enhancing the quality of nursing care and patient satisfaction.

Implementation of an Interdisciplinary Communication Workgroup on an Acute Psychiatric Unit

Communication among Interdisciplinary Healthcare Teams is an essential component of providing optimal patient care. Staff members at one U. S. Department of Veterans Affairs on an Acute Psychiatric Unit identified fragmented communication on the unit and expressed interest in forming an interdisciplinary communication workgroup. This quality improvement (QI) project was designed to enhance communication among the Interdisciplinary Healthcare Team on the Acute Psychiatric Unit. A workgroup was formed and met four times at 1-hour intervals. A pre/post-test was used to determine the initial effectiveness of the intervention. The results of the intervention suggested increased communication among the Interdisciplinary Healthcare Team as an upward trend of the mean scores was noted.

Improving visiting nurses’ post-hospital medication management

Purpose

Employing a participatory approach, the purpose of this paper is to identify possible areas for improvement in visiting nurses’ post-hospital medication management and to facilitate suggestions for changes in future practices.

Design/methodology/approach

Based on a previous study on visiting nurses’ post-hospital medication management, two workshops were conducted in a visiting nurse department in a Danish municipality.

Findings

The visiting nurses emphasised knowledge of patients’ basic needs and prioritised their performance of context-specific nursing assessments, with a preventive focus as a prerequisite for improved patient safety in post-hospital medication management.

Research limitations/implications

The participatory approach can increase the acceptability and feasibility of changes regarding future practices and thereby reduce the gap between official documents and daily practice. Although the local development of suggestions for changes in practices does not provide general knowledge, a subsequent detailed description of the changes in practices can promote transferability to other healthcare settings after local adjustments are made.

Practical implications

Flexible home healthcare, with stable relationships enabling the continuous assessment of the patient’s needs and symptoms, along with subsequent adjustments being made in care and medical treatment, might enhance patient safety in post-hospital medication management.

Originality/value

This paper adds to the knowledge of the need for integrated care in medication management in patients’ homes. It argues for primary healthcare professionals as “experts in complexity” and suggests a reconsideration of the purchaser-provider division of care to patients with unstable health conditions and complex care needs during the first days following hospital discharge.

The family medicine reference clinic: an example of interprofessional collaboration within a healthcare team

Since being introduced in 2011, family medicine reference clinics (FMRCs) have created several advantages in the treatment of patients, but have also drawn attention to areas where improvements could be made (Poplas Susič, et al., 2013). Consistent with competencies and experts, each chronic patient care protocol as well as the prevention protocol strictly follows guidelines or recommendations that define diagnostic and treatment as well as education pathways for patient care in a family medicine practice. They are harmonised and agreed with experts at different levels of healthcare (primary, secondary and tertiary) (Vodopivec Jamšek, 2013).