Clinical Nurse Leader An Emerging Advance Practice Role
The Clinical Nurse Leader (CNL) is a new specialization in Nursing
There is a documented need for the CNL role in assuring quality and cost effectiveness of nursing care
There are differences of opinion on education and classification
Origin of the Clinical Nurse Leader (CNL) Role
“… .unless nursing is able to create a professional role that will attract the highest quality women and men into nursing, we will not be able to fulfill our covenant with the public. The Clinical Nurse Leader (CNL) addresses the call for change.”
AACN (February 2007) White Paper on the
Education and Role of the Clinical Nurse Leader
Impetus for Change
In 1999 the AACN Board of Directors identified a number of primary concerns related to care delivery:
Declining enrollment in baccalaureate nursing programs
Lack of success in differentiating practice of RNs with different educational preparation
Exponentially increased knowledge base for nurses(e.g., genetics, pharmacology), along with increasingly complex delivery systems
Numerous landmark studies reporting lack of high-quality patient care
IOM landmark report To Err is Human: Building a Safer Health System (2000) focused on increasingly high rate of medical errors
JCAHO Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis (2002) recommended proposals for providing financial incentives for health care organizations to invest in high quality nursing care
RWJ’s Health Care’s Human Crisis: The American Nursing Shortage (2002) recommends “the reinvention of nursing education and work environments to address and appeal to the needs and values of a new generation of nurses”.
IOM Health Professions Education: A Bridge to Quality (2003): “ All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics .”
Development of the CNL
2002 an AACN task force created focused on needed nurse competencies
Clinical leadership in all health care settings
Implementation of outcomes-based practice and Quality Improvement strategies
Ability of RNs to practice at their full scope of education and ability
The creation and management of “microsystems” of care that will be responsive to the health care needs of individuals and families.
May 2003: Draft white paper The Role of the Clinical Nurse Leader
February 2007: White Paper on the Education and Role of the Clinical Nurse Leader
“… .perhaps creating a powerful financial return-on-investment model based on higher quality of care, shorter length of stay, and improved clinical outcomes will more than justify the cost of such a role” .
“ The CNL functions as a Masters-prepared generalist providing and managing care at the point of care to patients, individuals, families, and communities…….along with the authority, autonomy and initiative to design and implement care, the CNL is accountable for improving individual care outcomes and care processes in a quality, cost-effective manner.”
Nursing technology and resource management
Health promotion, risk reduction, and disease prevention
Illness and Disease management
Information and Health Care technologies
Global Health Care
Health Care Systems and Policy
Provider/Manager/Coordinator of Care
Fundamental Aspects of CNL
“ Lateral integration of care for a specified group of patients”
may actively provide direct patient care in complex situations
emphasis on health promotions and risk reduction
Responsibility for the ongoing assessment of the plan of care.
Has the decision-making authority to change care plans if necessary
Accountability for evaluation and improvement in point-of-care outcomes
Fundamental Aspects of CNL
Client and community advocate
Systems analyst/risk anticipator
Collaboration with other health professional team members
Member of a profession
“ I was educated to use research to define and solve practice problems, to look beyond the obvious outcomes and to work to discover the true essence of practice problems. Through research, I learned to define problems on the unit by analyzing decreased patient satisfaction scores, the nurse turnover rate, staff morale, and increasing stress levels. I worked within the practice environment and studied how problems were being solved daily and how the flowthrough the GI lab was affected by other variables within the unit itself I evaluated how happy staff were with the way problems were being addressed by management and how their work performance was affected by their overall satisfaction with their work environment.”
AACN holds the position that the CNL should be Master’s prepared.
CNL is an advanced generalist education.
65 schools in the U.S. offer a CNL program.
AACN Education Models for CNL
Model A: Master’s degree program for BSN graduates that includes a post-BSN residency that awards master’s credit.
Model B: Master’s program designed for ADN graduates (RN-MSN).
Education Models cont.
Model C: Master’s Program designed for individuals with a baccalaureate degree in another discipline (second-degree program).
Model D: Master’s degree program designed for BSN graduates.
Model E: Post-master’s certificate program designed for individuals with a master’s degree in nursing in another area of study.
AACN requires that the nurse meet the following criteria
Registered Nurse licensure
Graduation from an accredited CNL master's or post-master’s program
CNL exam is w eb-based
Two-part process involving multiple choice and simulation questions
Graduate Level Curriculum Elements CNL Role Functions CNL Role Expectations Nursing Leadership Advocate
Keeps clients well informed
Includes clients in care planning
Advocates for the profession
Works with interdisciplinary team
Strives to achieve social justice within the microsystem
Member of a Profession
Effects change in health care practice
Effects change in health outcomes
Effects change in the profession
Care Environment Management Team Manager
Properly delegates and manages
Uses team resources effectively
Serves as leader/partner on interdisciplinary team
Uses information systems/ technologies
Improves health care outcomes
Systems Analyst/Risk Anticipator
Participates in system reviews
Evaluates/anticipates client risks to improve patient safety
Clinical Outcomes Management Clinician
Delivers care in a timely, cost effective manner
Emphasizes health promotion/risk reduction
Clinical Outcomes Management Outcomes Manager
Uses data to change practice and improve outcomes.
Achieves optimal client outcomes
Clinical Outcomes Management Educator
Uses teaching/learning principles/strategies
Uses current information/ materials/techniques
Facilitates clients learning, anticipating their health trajectory needs.
Facilitates client care using evidence-based resources.
Facilitates group & other health professions’ learning and professional development
Is CNL by definition an advanced practice role?
Advance practice registered nurse (APRN) is not defined in Washington Nurse Practice Guide (WDOH, 2005)
The CNL is not prepared as an advanced registered nurse practitioner (ARNP) as the ARNP is currently defined (WDOH, 2005)
APRN is a generic, umbrella term that encompasses ARNPs, CNSs, nurse anesthetists and nurse midwives. (APRN-JDC, 2008)
Does CNL function in advanced practice role?
The CNL is an advanced generalist, functions at the unit level, and isn’t a patient population expert in contrast with the specialized focus of the practice by CNS and ARNP.
CNS and ARNP is prepared in a specialty curriculum which includes those clinical and didactic learning experiences identified and defined by the specialty nursing organization for the particular area of advanced clinical practice.
Is CNL educated for advanced practice role?
Educated at the master’s degree, the CNL is prepared with nursing competencies as outlined in the AACN (1998) Essentials of Baccalaureate Education for Professional Nursing Practice and additional competencies as outlined in the Working Paper on the Role of the Clinical Nurse Leader (AACN, 2004a).
In comparison, the CNS is also prepared at the master’s level but is prepared at the advanced practice level with competencies as outlined in AACN’s (1996) Essentials of Master’s Education for Advanced Practice Nursing (AACN, 2004c)
Is CNL an MSN advanced practice role?
AACN is proposing that we move our clinical master’s advanced practice nursing degrees (CNS, NP, CRNA and CNM) toward the practice doctorate.
The CNL will be a Masters prepared nurse
The CNL will serve in a unit-based role in the place of a unit-based CNS and ideally in conjunction with a DNP
Is CNL an emerging advanced practice role?
CNL is an emerging nursing role developed by the American Association of Colleges of Nursing (AACN) in 2003
The expectations for the CNL seem formidable with the many responsibilities identified
CNL role clearly overlaps with the CNS role in many areas.
Both the CNL and CNS manage care that is responsive to the health care needs of individuals and families.
The CNL and CNS design and provide health promotion and risk reduction services for patients.
The CNL is a unique and valuable nursing role
The verdict is still out on recognition of CNL as an “advance practice” role
Standardization and legislation for title recognition and educational requirements is needed to formalize the role
AACN, 2008. CNL Frequently Asked Questions. American Association of Colleges of Nursing. http://www.aacn.nche.edu/CNL/FAQ.htm Accessed 9-29-08.
American Association of Critical Care Nurses, 2008. Advanced Practice Roles: CNS or NP? What’s in a Name? American Association of Critical Care Nurses. http://classic.aacn.org/AACN/aacnnews.nsf/ff1487bfe89b77df882565a6006cfc3f/2ae0e849ab5ec4e188256b5a007cd35e?OpenDocument#roles . Accessed 9-29-08.
APRN-JDC, 2008. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education . APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory Committee. July, 2008.
Grindel C. (2005). AACN Presents the Clinical Nurse Leader and the Doctor In Nursing practice Roles: A Benefit or a Misfortune? MEDSURG Nursing, Vol. 14/No.4, pg 209-210.
Institute of Medicine. (2003). Health professions education: A bridge to quality . Washington, DC: The National Academies Press.
Joint Commission on Accreditation of Healthcare Organizations. (2002). Health care at the crossroads, Strategies for addressing the evolving nursing crisis. Chicago.
Kimball, B. & O’Neill, E. (2002). Health care’s human crisis: The American nursing shortage. Princeton, NJ: The Robert Wood Johnson Foundation.
Spross J, Hamric A, Hall G, et al. Working statement comparing the clinical nurse leader and clinical nurse specialist roles: similarities, differences, and complementarities. Washington, DC: American Association of Colleges of Nursing; 2004.
WDOH, 2005. Nursing Practice Guide. Washington State Department of Health, Nursing Care Quality Assurance Commission. December 2005
Institute of Medicine. (2000). To Err is Human: Building a Safer HealthSystem . Washington, DC: National Academy Press.