Developing the Clinical Nurse Leader Survey Instrument: A Modified Delphi Study

Clinical Nurse Leader Practice Development: An Integrative Review of the Literature

BACKGROUND

The Clinical Nurse Leader (CNL) is a skilled clinician qualified in outcomes-based practice and quality improvement. Publications describe the CNL training, integration, and outcomes. However, CNL practice development and its impact has not been fully explored.

PURPOSE

This review aimed to synthesize existing literature related to CNL practice development and identify what influences on the care environment and nursing care outcomes.

METHODS

An integrative literature review was conducted in 5 bibliographic databases for sources published in English from January 2012 to March 2023.

RESULTS

Fifteen publications identified 3 interrelated themes of CNL practice, outcomes, and practice development. Staff development needs were identified across various levels of expertise.

CONCLUSION

There is a need to further explore CNL practice development and how it can impact the care environment and care outcomes.

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.

Factors Influencing Implementation Success of the Clinical Nurse Leader Care Delivery Model: Findings From a National-Level Mixed-Methods Study

BACKGROUND

The clinical nurse leader (CNL) care model has existed since 2007. However, there is limited understanding how the model can best be implemented.

PURPOSE

A validated CNL Practice Survey measuring domains theorized to influence CNL implementation was used to examine the link between CNL domains and CNL implementation success.

METHODS

Mixed methods were used to analyze data from a nationwide 2015 survey administered to clinicians and administrators involved in CNL initiatives.

RESULTS

Of total respondents (n = 920), 543 (59%) provided success scores, with 349 (38%) providing comments. Respondents with negative comments gave significantly lower average CNL success scores. The majority of negative comments mapped onto Readiness and Structuring domains, providing details of barriers to CNL implementation success.

CONCLUSIONS

Findings provide information about structural domains that can be strategically targeted to better prepare settings for CNL implementation and success.

Designing and Using Surveys in Nursing Research: A Contemporary Discussion

This commentary summarizes the contemporary design and use of surveys or questionnaires in nursing science, particularly in light of recent reporting guidelines to standardize and improve the quality of survey studies in healthcare research. The benefits, risks, and limitations of these types of data collection tools are also briefly discussed.

A study protocol to evaluate the implementation and effectiveness of the Clinical Nurse Leader Care Model in improving quality and safety outcomes

Aims

Patients are harmed or die every year because of unsafe, inappropriate or inadequate healthcare delivery. Registered Nurses are a recognized patient safety strategy. However, variability in research findings indicate the relationship is not as simple as “more nurses=better outcomes.” Hence, currently there exists no evidence‐based frontline nursing care model. One emerging model is the Clinical Nurse Leader care model.

Design

This Hybrid Type II Implementation‐Effectiveness study will evaluate the effect of the care model on standardized quality and safety outcomes and identify implementation characteristics that are sufficient and necessary to achieve outcomes.

Methods

This study leverages a natural experiment in 66 clinical care units in nine hospitals across five states in the United States that have implemented the Clinical Nurse Leader care model.

Results

Findings will elucidate Registered Nurse's mechanisms of action as organized into frontline models of care and link actions to improved care quality and safety.

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.