The clinical nurse leader role, introduced more than a decade ago as way to improve patient outcomes, patient safety, and quality of care, has been delivering promising, but mixed results in one Florida hospital system, which was an early adopter.
The more things change, the more they stay the same. Cliché? Some might say so, but at times it seems more like a universal law of healthcare.
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Yes, technology has changed immensely in recent years and the Patient Protection and Affordable Care Act has introduced some new challenges since its passage in 2010, but we're still grappling with many of the same issues that we were two decades ago.
Take medical errors, patient safety, quality of care, and patient outcomes, for example. Those are hot topics these days, but they've been around for a long time. In fact, those were some of the very reasons the American Association of Colleges of Nursing introduced the clinical nurse leader role in 2003.
The History of the CNL
The CNL is a master's-prepared advanced generalist who works at the point of care and applies evidence-based information to influence patient care methods and outcomes. Because the focus of the CNL is on coordinating care across multiple disciplines, The Clinical Nurse Leader Association likens the role to that of an air-traffic controller.
The CNL role began taking shape in 1999 shortly after the Institute of Medicine released its report "To Err is Human," which highlighted the need to improve healthcare quality by reducing medical errors. In response, the AACN created two task forces to determine how to improve the quality of patient care and how to best prepare nurses to provide high-level care in a changing healthcare system.
After much research and discussion, the CNL role—the first new nursing role in 35 years—was born.
Diane Raines, DNP, RN, NEA-BC, senior vice president and chief nursing officer at Baptist Health in Northeast Florida, says her organization saw the value of the CNL role from the get-go.
"In our children's hospital, we were early adopters," says Raines, who credits her colleague Carolyn Johnson, RN, with having the vision to use CNLs as soon as they became available clinically. "She really grabbed on to that role because she saw a need for a coordinating generalist on the unit."
Care Coordination a Key Skill
The CNL role eventually expanded beyond the children's hospital and there are now 30 CNL/navigators across five Baptist Health hospitals.
"When we were looking for ways to improve the patient's experience, to improve care coordination and meet our quality measures, that role reemerged in our discussion," Raines says. Their broad education and focus on care coordination made CNLs appealing. "For what we were trying to do, which is coordinate care of complex patients to make sure their discharge went better, the CNL role was an ideal preparation," Raines says.
Finding CNLs to fill the new positions was not an easy task, however, and the nurse leaders at Baptist Health had to get creative. When the organization realized that there weren't a lot of CNLs out there waiting to be hired, it "converted some of our advanced practice nurses or educators to that role," she says.
Now the job is called CNL/navigator. Those with CNL preparation are called CNLs, and those without the certification, such as APNs, are called navigators. They are responsible for helping coordinate interdisciplinary rounds and working with the nursing staff, social services, physicians, physical therapy, and other members of the care team. They help staff plan for difficult discharges so patients are educated appropriately and medications are reconciled correctly.
They also assist with the "hand-off into the community" by making the patient's appointment with the physician for follow-up care. If the patient doesn't have a physician, the CNL will help to find one.
"They're kind of the glue that keeps the care moving forward," Raines says. "We're trying not to have these complex patients just leave without that follow-up care because, of course, what happens is they come back," Raines says. Finally, the CNL/navigator can also function as a preceptor and mentor to new staff on the unit.
Measurable Results
When I asked Raines if the CNL role created the results Baptist was hoping for, she responded, "Yes, and we still have plenty of opportunity." Metrics have shown that when it comes to quality of care, readmission rates, and patient satisfaction rates, improvements have not been consistent across the board and some units been successful while others have "struggle[d] a little bit more."
And while quality markers improved significantly, surprisingly, the CNL role did not seem to affect patient satisfaction rates.
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Despite the understandable bumps along the way, Baptist Health has seen strong improvements in its quality metrics. "Those continue to improve on an annual basis," she says.
According to Raines, bloodstream infections and pressure ulcers are practically at zero. As a system, there's been a gradual trending downward of readmissions rather than a sharp decline. "We'd like to see that stronger," Raines says.
Falls continue to decrease, and though they still have more than they like, the numbers are the lowest they've ever been. UTI rates have not improved, so a navigator and an infection prevention specialist are now focusing on ways to decrease those rates.
"We were having inconsistent methods for [catheter] insertion and that gives the navigator on their unit the opportunity to focus on technique," says Raines.
One point to keep in mind is, that the nurse navigator or CNL "does not work in a vacuum," she says. "So part of the success of a program like this is [that] you've got to have a strong physician partnership, you've got to have committed social workers, etc. We still have a ways to go."
Join Diane Raines and Mary Leen of Baptist Health for a HealthLeaders webcast, "New Nursing Roles: Baptist Health's Innovative Inpatient & Outpatient Models" on April 29 from 1:00–2:00 PM ET.
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.